Are you putting children through unnecessary trauma in your ED?
New guidelines say RSV testing isn’t usually necessary
When a child comes to your ED wheezing and congested, it may be standard practice to test for respiratory syncytial virus (RSV). But testing for RSV is painful, costly, and unnecessary in many cases, argues Jennifer Dearman, RN, BN, charge nurse at the pediatric ED at Loma Linda (CA) University Medical Center and Children’s Hospital.
Bronchiolitis is caused by RSV in 85%-90% of cases, notes Dearman, and it can be life-threatening in some children. However, new guidelines published by the Alexandria, VA-based National Association of Children’s Hospitals and Related Institutions (NACHRI) state that — contrary to common practice — not all children with bronchiolitis symptoms should be tested for RSV. (See resource box, p. 14, for information on obtaining the guidelines.)
During RSV testing, nurses obtain a nasopharyngeal wash, which is a traumatic and invasive procedure, explains Dearman. "It involves introducing a catheter into the nose to the nasopharynx, instilling saline, and aspirating the saline," she says. "Children always gag during this procedure."
There is also a risk of laryngospasm for asthmatic children, she adds.
A hospitalwide committee that included representation from epidemiology, infectious diseases, administration, pediatrics, and the ED, looked at the number of cases tested for RSV. "Of the children tested in the ED in 1998, only 12% were positive for RSV," reports Dearman. "We revised our policy on testing, due to the fact that we were obviously overtesting."
Previously, all small children who came to the ED had to be cultured with the results returned before they could be admitted, explains Darlene Bradley, RN, MSN, MAOM, CCRN, CEN, clinical director for emergency/express care at Loma Linda. "This created many delays in the admission process, more expense waiting for labs that may not have been necessary, and prolonged holds in the ED until an isolation bed on the pediatric unit could be made available," she recalls. (See story on preventing transmission of RSV, p. 20.)
The practice impeded patient flow significantly, Bradley says. "Children with RSV have been like a plague to us for many years," she stresses. (See story on medications, p. 17; the use of bronchodilators, p. 18; and distinguishing between pertussis and RSV, p. 20.)
It used to be common practice to test all children during the winter/flu season before bed placement could be provided. "We then worked with pediatrics, epidemiology, and emergency services to change that standard," says Bradley. "We now save children the discomfort of the procedure and the family the expense."
Most children don’t need an RSV test
At Loma Linda, children are only tested for RSV if they are less than three years old and have a fever without focus and/or respiratory signs and symptoms (rhinorrea, wheezing, increased work of breathing, respiratory distress, cyanosis, and apnea).
At The Children’s Hospital ED in Denver, RSV tests are not given in most cases, reports Carol Ledwith, MD, FAAP, an attending physician in the ED.
"We will only test if we think the results will significantly change management," she explains. "Any child who comes to the ED with clinical bronchiolitis will not automatically get tested, whether they are getting admitted or going home."
There is no reason to do this test outside of specific criteria, based on the guidelines set forth by NACHRI, Ledwith stresses. Any invasive procedure such as nasal suctioning should not be done without considering the benefit for the patient and implications for management, she adds.
The Children’s Hospital created guidelines based on the new testing requirements, with representation from the ED, pulmonary, respiratory therapy, nursing, and infectious disease. (See guidelines for management of bronchiolitis in the ED, p. 15 and above.)
When should you test for RSV?
The Children’s Hospital guidelines state that only the following children should be tested in the ED:
• high-risk children who may need antiviral therapy;
• children with congenital heart disease;
• premature infants;
• children with bronchopulmonary dysplasia;
• children with immunosuppression;
• children with chronic lung disease;
• infants less than eight weeks of age who are febrile;
• infants who require hospitalization to establish the source of fever and/or avoid unnecessary testing and treatment.
For example, an extremely ill infant having apneic episodes should be tested, Ledwith explains. "In that case, if you know it’s RSV, then you might not have to do extensive further testing, such as CAT scans or upper GIs," she says.
RSV testing can also avoid children being worked up for sepsis and pneumonia, which includes getting complete blood counts and blood cultures, says Ledwith. A full sepsis workup will usually be done for babies with fever without a source. "But you don’t need to work these kids up routinely for fever without a source, if the diagnosis of bronchiolitis has been made," she explains. (See story on management tips for RSV, p. 19.)
The diagnosis for bronchiolitis can be made clinically, eliminating the need for further testing, she explains.
If a child is a premature baby or has congenital heart disease, or you are considering the use of Ribavirin (virazole), manufactured by ICN Pharmaceuticals in Costa Mesa, CA, you should document if it’s RSV. "But those are the minority of our cases," stresses Ledwith.
Every child with bronchiolitis does not need a chest X-ray, says Ledwith. In general, a chest X-ray is warranted for an infant who is not resolving his or her symptoms over the expected natural course of the illness, which would be five to seven days, Ledwith says.
"The average bronchiolytic peaks at day three to five and is done by day seven," she notes.
Don’t order a chest X-ray for every child
If the child has a higher fever than expected, consider obtaining a chest X-ray, Ledwith recommends. "Chest X-rays are also appropriate if you have a history of a possible choking episode and want to rule out a foreign body, or a history consistent with congenital heart disease that hasn’t been picked up."
All children with crackles used to receive chest X-rays automatically. "But the fact is, crackles are very common with bronchiolitis, probably more so than wheezing," Ledwith says. "The presence of crackles alone does not mean the child should get a chest X-ray."
The presence of some asymmetry is also not reason enough to order a chest X-ray, Ledwith advises. "Bronchiolitis is by nature very asymmetric and rapidly changing," she says. "If you listen to those kids, one minute they are different from the next and may be intermittently quite asymmetric."
If the patient’s chest exam is markedly asymmetric, such as clear on one side, and with dense crackles in a focal area on the other, a chest X-ray would be indicated, Ledwith recommends. "But people overuse that rule and tend to get a lot of chest X-rays. Often, the X-ray tells you only that it is consistent with bronchiolitis. That doesn’t change the management, and is a significant expense."
Children with bronchiolitis may be referred to the ED specifically for a chest X-ray, notes Ledwith. "They’re sent in for a chest X-ray as if it’s the standard workup, but it’s not," she says. "That’s a dogma that has been passed on for 20 years and probably needs to be changed."
References
National Association of Children’s Hospitals and Related Institutions (NACHRI) Practice Opportunity/Benchmark guidelines, RSV Laboratory Evaluations for Patients with Uncomplicated Bronchiolitis and RSV Laboratory Evaluations are not Routinely Done in the ED to Determine Admission and/or Bed Placement, both developed by NACHRI’s Emergency Department Focus Group, are available to focus group hospitals. For more information about focus groups, contact:
• Gregory Frangello, Director, Applied Consulting Services, NACHRI, 401 Wythe St., Alexandria, VA 22314. Telephone: (703) 684-1355. Fax: (703) 519-8553. E-mail: [email protected]. Web site: www.childrenshospitals.net.
For more information about management of respiratory syncytial virus in the ED, contact:
• Darlene Bradley, RN, MSN, MAOM, CCRN, CEN, Emergency/Express Care, Loma Linda University Medical Center and Children’s Hospital, 11234 Andersen St., Loma Linda, CA 92354. Telephone: (909) 478-8077.Fax: (909) 824-4641. E-mail: [email protected].
• Jennifer Dearman, RN, BN, Pediatric Emergency Department, Loma Linda University Medical Center and Children’s Hospital, 11234 Andersen St., Loma Linda, CA 92354. Telephone: (909) 824-4344. Fax: (909) 824-4054. E-mail: [email protected].
• Carol Ledwith, MD, FAAP, The Children’s Hospital, B-251, 1056 E. 19th Ave., Denver, CO 80218. Telephone: (303) 837-2844. Fax: (303) 764-8694. E-mail: [email protected].
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content