Guideline-Discordant Bronchiolitis Care in Community Emergency Departments

Many children with bronchiolitis receive tests and treatments that are not recommended by the American Academy of Pediatrics (AAP) in community emergency departments (EDs). This guideline-discordant care (GDC) increases patient risk, hospital costs, and ED length of stay (LOS). Few studies have investigated the impact of AAP guidelines on the current burden of GDC in community EDs or factors associated with receiving this low-value care. A contemporary benchmark of GDC in community EDs is necessary to develop and implement intervention to improve care delivery.

Our retrospective observational study of children with bronchiolitis from 2017–2024 included patients 28 days–2 years old without significant chronic comorbidities precluding application of AAP bronchiolitis guidelines. All patients were discharged from a community ED in our Northern California health system. Outcomes were GDC defined as receiving one or more tests or treatments not recommended by the AAP (albuterol, chest radiography, steroids, antibiotics and racemic epinephrine) and ED LOS. We examined patient and clinical characteristics associated with GDC and its association with ED LOS using multivariable regression.

There were 6,083 eligible encounters from 5,989 unique patients. The majority of children with bronchiolitis (62%) received GDC with chest radiography (41%) and albuterol (37%) being most common. GDC was associated with longer median ED LOS (142 min, 95% CI: 140—145 min) compared with no GDC (84 min, 95% CI: 82—86 min). Receipt of both albuterol and chest radiography was associated with the longest lengths of stay [177 min (95% CI: 172 –182 min)]. After adjustment, abnormal vital signs, older age, male sex, and past albuterol exposure were associated with increased likelihood of GDC.

GDC was common over the study period and associated with longer ED LOS. Important patient-level factors may increase the likelihood of GDC. Interventions that mitigate GDC are high-yield opportunities to improve care delivery in community EDs.