Which Infant with Bronchiolitis will Bounce Back to the ED?
June 1, 1997 3 minutes read
Which Infant with Bronchiolitis will Bounce Back to the ED?
ABSTRACT & COMMENTARY
Synopsis: Only 57 of 1776 infants evaluated in the ED for bronchiolitis who were not hospitalized subsequently returned to the ED. Compared to infants who did not return to the ED, there were no statistical differences in initial oxygen saturation, history, or physical findings.
Source: Roback MG, Baskin MN. Failure of oxygen saturation and clinical assessment to predict which patients with bronchiolitis discharged from the emergency department will return requiring admission. Pediatr Emerg Care 1997;13:9-11.
It has long been recognized that patients who make an unscheduled return visit to the ED during the course of a given illness are at increased risk in terms of misdiagnosis and errors in management. Roback and Baskin retrospectively reviewed the records of 57 infants younger than 1 year of age who made a return visit for bronchiolitis and were admitted. As a control group, they selected 124 patients who did not return requiring admission. Comparisons of clinical features and oxygen saturation were made between the study patient and control groups.
Over the course of an 18-month period, 1776 infants with bronchiolitis were evaluated in the emergency department of a large urban children’s hospital. Only 57 of these patients (4.6%) were discharged only to be hospitalized on a return visit. When compared with the controls, no statistically significant differences were found in initial oxygen saturation (SaO2 = 97.6% in cases, 98.0% in controls). Multiple demographic, historical, and physical examination findings were also compared. Only the difference in mean heart rate was statistically significant (154.8 in controls, 148.8 in controls; P = 0.006).
As a group, those patients who were admitted at the time of a return ED visit did well clinically. None required intensive care unit admission. At the time of the return visit, patients who were admitted had a lower SaO2 than at the time of the initial visit (95.9% vs 97.7%; P = 0.001) as well as a higher frequency of retractions (83.3% vs 52.6%; P = 0.02). Follow-up was made by telephone and additional chart review of 55 control patients so as to determine whether any of them were hospitalized elsewhere; only one of 55 was admitted to another facility.
COMMENT BY DAVID BACHMAN, MD, FAAP
I maintain that physicians caring for children in office and ED settings uniformly cringe with the onset of bronchiolitis season. One of the reasons for our dismay is the difficulty in distinguishing infants with bronchiolitis who will have a severe course from those who will not. The decision regarding disposition is not difficult with those infants who are younger than 2-3 months, toxic, markedly tachypneic (respiratory rate > 60), hypoxic (SaO2 < 90%), dehydrated, or premature, particularly if there is underlying cardiopulmonary disease. And the decision-making is not hard when the child is alert and playful with only mild wheezing and an oxygen saturation greater than 95%. The trouble is the large group of infants who fall between these two extremes.
I do appreciate the efforts of Roback and Baskin to identify criteria that might help us to identify those children who will later require admission earlier in the course of their illness. Unfortunately, they could only demonstrate that there really are no useful distinguishing criteria (the difference in heart rate is statistically significant but not clinically significant). Their study is a bit compromised by the fact that it is retrospective. In addition, as best I can tell, the physicians who made the decision whether to admit the study patients were not blinded to the fact that they had previously been evaluated in the ED and discharged. A decision to admit an ED patient is inevitably influenced by the fact that they have made a return visit (I have heard it suggested that if a patient makes three ED visits for the same problem, admission is essentially mandated). As a group, the control patients were not much more hypoxic at the time of the second visit than initially. The actual criteria for admission in a given case was determined by the attending physician on duty at the time and were doubtless not uniform.
It was encouraging that all the patients who returned and required admission did well clinically. With bronchiolitis, the importance of careful discharge instructions and close communication with and follow-up by the primary physician remains paramount. Whether further study will better define at-risk groups is uncertain.
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