Improving Pediatric Intensive Care Unit Discharge Timeliness of Infants with Bronchiolitis Using Clinical Decision Support

Abstract

Background Identifying children ready for transfer out of the pediatric intensive care unit (PICU) is an area that may benefit from clinical decision support (CDS). We previously implemented a quality improvement (QI) initiative to accelerate the transfer evaluation of non–medically complex PICU patients with viral bronchiolitis receiving floor-appropriate respiratory support.

Objectives Design a CDS tool adaptation of this QI initiative to further accelerate transfer evaluation of appropriate patients.

Methods The original initiative focused on identifying for transfer evaluation otherwise healthy children admitted to the PICU with bronchiolitis who had been receiving floor-appropriate levels of respiratory support for at least 6 hours. However, this initiative required that clinicians manually track the respiratory support of qualifying patients. We designed an electronic health record (EHR)–based CDS tool to automate identification of transfer-ready candidates. The tool parses EHR data to identify children meeting prior QI initiative criteria and alerts clinicians to assess transfer readiness once a child has been receiving floor-appropriate respiratory support for 6 hours. We compared time from reaching floor-appropriate support to placement of the transfer order (“time-to-transfer”), PICU length of stay (LOS), and hospital LOS between patients admitted prior to our QI initiative (December 1, 2018–October 19, 2019, “pre-QI phase”), during the initiative but before CDS tool implementation (October 20, 2019–February 7, 2022, “QI phase”), and after CDS implementation (February 8–November 11, 2022, “CDS phase”).

Results CDS-phase patients (n = 131) had a shorter median time-to-transfer of 5.23 (interquartile range [IQR], 3.38–10.0) hours compared with QI-phase patients (n = 304) at 5.93 (IQR, 4.23–12.2) hours (p = 0.04). PICU and hospital LOS values decreased from the pre-QI (n = 150) to QI phase. Though LOS reductions were sustained during the CDS phase, further reductions from QI to CDS phase were not statistically significant.

Conclusion An EHR-based CDS adaptation of a prior QI initiative facilitated timely identification of PICU patients with bronchiolitis ready for transfer evaluation. Such tools might allow PICU clinicians to focus on other high-acuity tasks while accelerating transfer evaluation of appropriate patients.

Keywords

bronchiolitis - pediatric critical care - clinical decision support - electronic health record - de-escalation

Protection of Human and Animal Subjects

The study was performed in compliance with the World Medical Association Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects and was approved by the Children's Hospital Colorado Organizational Research Risk and Quality Improvement Review Panel (ORRQIRP) Review Panel.

Publication History

Received: 09 September 2022

Accepted: 13 February 2023

Accepted Manuscript online:
15 February 2023

Article published online:
17 May 2023

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