Bronchiolitis, a lower respiratory tract infection that predominantly affects infants and children younger than two years of age during the fall and winter months, has been shown to be a leading cause of hospitalization for children younger than 5 years of age. This disease process takes on both severe and non-severe forms with evidence that outpatient treatment for the non-severe form is optimal and desirable for patients. Factors that predict mild disease without need for high flow nasal cannula, intensive care unit, non-invasive ventilation and intubation include: >2 months old, oxygen saturation ≥ 90%, no nasal flaring, no grunting, no retractions, and adequate hydration (1). Several studies from Children’s Hospital Colorado have shown that it is safe and cost effective for a select group of hypoxic but otherwise low-risk patients to be discharged from the emergency department (ED) on home oxygen. Home oxygen has been the standard of care for otherwise well- appearing bronchiolitis patients at Children’s Hospital Colorado for over 10 years (2,3). Of note, the University of New Mexico (UNM) Hospitalist Team and Pediatric Urgent Care have also prescribed home oxygen for more than 5 years.
The UNM Pediatric ED initiated an evidence-based Home Oxygen Pathway in 2017 with goals of reducing the burden of hospital admissions during bronchiolitis season, eliminating risk of patient exposure to additional infectious agents during admission, and providing patients and families with the appealing option of avoiding an inpatient stay. This pathway parallels the evidence-based standard of care Home Oxygen Pathway used at Children’s Hospital of Colorado and is intended for low-risk bronchiolitis patients who require supplemental oxygen. Our low risk criteria include: age 3-36 months, corrected gestation age > 48 weeks, no history of chronic medical illness, no history of apnea, history and exam consistent with bronchiolitis, well appearing without significant increased work of breathing, maintaining good oral hydration, oxygen saturation remains ≥ 90% on ≤ 0.5LPM oxygen, caregiver comfortable with possible discharge home, family able to follow up easily (<30 minute travel time to the hospital, available transportation and telephone). Patients meeting these criteria are discharged home on oxygen after an ED observation period.
This quality improvement project aims to demonstrate the efficacy and safety of the UNMH ED Pediatric Home Oxygen Pathway by describing the outcomes of those placed on this pathway
We review existing quality reports which include all Pediatric Emergency Department patients who are placed on the PED Home Oxygen Pathway and/or discharged on home oxygen from the Pediatric Emergency Department. We utilize a Redcap database to record information about each encounter, including demographic information, details of the initial Emergency Department visit and observation period, disposition, and follow-up information. We review cases to identify any evidence of any adverse outcomes after ED discharge. We examined charts to determine whether discharged home oxygen patients had any repeat ED visits, admission to the hospital within 7 days of ED discharge, and if so if the admission was associated with any adverse events.
Data collected from December 2017-May 2020 revealed 38 children placed into our ED observation unit. Fourteen patients were admitted to the hospital after the ED observation period. The reasons for admission included: increased oxygen requirement (9 patients), increased work of breathing (5 patients), caregiver discomfort with discharge (2 patients) and provider discomfort with discharge (1 patient). None of the patients admitted required admission to the PICU or intubation. Three patients required high flow nasal canula oxygen delivery. Of the 24 patients who were discharged home after the ED observation period, there was no evidence of hospital admission after discharge. Two patients had a return visit to the ED and both were discharged home.
Our data supports the safety of our current home oxygen protocol. None of our discharged home oxygen patients returned to the hospital and required admission. The Children’s Hospital of Colorado found that patients who were later admitted after discharge home with oxygen were more likely to be admitted to the PICU or require HFNC compared to patient admitted as an initial disposition; this was based upon n = 11, out of 225 patients discharged home on oxygen. While our limited sample set included no such patients, ongoing data collection is needed for future bronchiolitis seasons. Due to our small sample size, we aren’t able to quantify a rate of reduction in hospital admission; however, the Children’s Hospital of Colorado reported an absolute admission rate reduction of 9% over four seasons. One limitation of our data is that patients may have returned to other hospitals and we do not have that information.
As a result of the COVID-19 global pandemic, our pediatric ED patient volumes during the 2020-21 winter season were exceptionally low and we cared for very few bronchiolitis patients. However, we expect use of the home oxygen pathway to grow once our patient volumes rebound.
The UNM Pediatric Emergency Department Home Oxygen Pathway is a safe disposition alternative for low-risk children with a non-severe presentation of bronchiolitis. The pathway prevents some hospital admissions for bronchiolitis. Further study may compare this cohort with admitted bronchiolitis patients who are quickly discharged (within 24 hours) on home oxygen to identify further opportunities to prevent brief hospital admissions in favor of ED observation and discharge on home oxygen.
We anticipate future steps to include further data collection and analyses and increased provider education for identifying home oxygen candidates.
- Freire et al., “Predicting Escalated Care in Infants With Bronchiolitis.” PEDIATRICS Volume 142, number 3, September 2018:e20174253
- Freeman, Julia Fuzak, et al. “Emergency Department-Initiated Home Oxygen for Bronchiolitis: A Prospective Study of Community Follow-up, Caregiver Satisfaction, and Outcomes.” Academic Emergency Medicine, vol. 24, no. 8, Aug. 2017, pp. 920–929., doi:10.1111/acem.13179.
- Bajaj, Lalit, et al. “A Randomized Trial of Home Oxygen Therapy From the Emergency Department for Acute Bronchiolitis.” Pediatrics, vol 117, no. 3, Mar, 2006, pp. 633-640.
Johnson, Molly; Jennifer Thompson; Adinda Demske; Rachel King; Rachel Tuuri; and Kjirsten Swenson. "A Retrospective Study Tracking Patient Outcomes for the UNMH Pediatric ED Home Oxygen Pathway for Bronchiolitis Patients." (2021). https://digitalrepository.unm.edu/hsc_qips/66