When to discharge paediatric bronchiolitis patients from ED safely?
Allowing for an observation period of between 11 to 25 hours is necessary for assessing the risk of delayed desaturation in hospitalised infants with bronchiolitis, according to a study. This should guide the identification of infants who may be immediately and safely discharged from the emergency department (ED).
“A decrease in oxygen saturation is one of the most important factors for hospitalisation and the most common barrier to discharge home for infants with bronchiolitis,” the investigators said.
Current guidelines and other recent publications cite the use of the pulse oxygen saturation (SpO2) threshold of 90 percent as one of the criteria for hospitalisation and for safe discharge after hospitalisation. Swiss guidelines, on the other hand, follow the SpO2 <92 percent threshold.
“However, there is no clear recommendation regarding the ED observation period necessary before allowing safe discharge home for patients with SpO2 above 90 to 92 percent,” they said.
“In the present study, it is interesting to note that most of the infants (70 percent) hospitalised for oxygen supplementation arrived at the emergency department with a normal SpO2 (≥92 percent), and showed a delayed desaturation during their stay,” they added.
The mean oxygen desaturation delay was longer for infants aged <3 months than for those aged ≥3 months (6 vs 3 hours; p=0.0018). This decrease in saturation occurred within 25 hours in younger infants and within 11 hours in older infants. [PLoS One 2016;doi:10.1371/journal.pone.0163217]
Among younger infants, the desaturation occurred earlier in those with respiratory rates above the normal range for their age than in those with normal respiratory rates (4.4 vs 14.6 hours; p=0.037).
On multivariate analysis, delayed desaturation was predicted by the following: age <3 months (odds ratio [OR], 4.2; 95 percent CI, 2.6 to 6.9; p<0.001), moderate/severe retractions (OR, 2.6; 1.6 to 4.3; p<0.001), ED readmission (OR, 3.6; 1.6 to 8.1; p=0.002), female sex (OR, 1.7; 1 to 2.7; p=0.036), and respiratory rate >normal for age (OR, 1.9; 1.1 to 3.2; p=0.017).
Only female sex and moderate/severe retractions risk factors remained statistically significant for delayed desaturation in the group of infants aged <3 months (p=0.036 and p=0.009, respectively).
The study cohort comprised 581 bronchiolitis patients aged <1 year and admitted to the ED. Of these, only 8 percent had had SpO2 <92 percent at presentation, although 18 percent exhibited a delayed desaturation (to <92 percent) during ED observation.
The five-step guide to discharging infants from the ED
These findings underscore the value of identifying the risk factors for delayed desaturation and standardising management procedures in EDs, the investigators said.
With the present data as a basis, “we propose a five-step guide for paediatricians on discharging children with bronchiolitis from the ED,” they added.
The first step is to identify patients with risk factors for a delayed desaturation (age <3 months, ED readmission, and a more severe initial clinical presentation). The second step is to allow an ED observation period of 11 hours for patients aged ≥3 months and 25 hours for patients aged <3 months. The third step is to discharge patients home if no desaturation occurs within the recommended observation period, and if the patients are feeding well.
“[H]owever, the paediatrician should be aware that an elevated [respiratory rate] is a major risk factor for ED readmission,” the investigators said.
The fourth step is to provide “anticipatory guidance instructions to the caregivers of those children at high risk; they should be advised to return for a reevaluation in cases of worsening respiratory distress or if the child is feeding less than 50 percent of the daily required amount,” they said.
Finally, the fifth step requires reevaluation of the patients 12 hours after ED discharge. This is particularly important in younger patients (<3 months) and in ED readmissions.
“Steps 4 and 5 are relatively subjective and are good practice suggestions [whereas] steps 1 to 3 are based on our results,” they said.
The investigators are hopeful that the guide may help clinicians in the management of children with bronchiolitis and reduce practice variability and the subsequent costs associated with hospitalisations for this condition.
Prospective and cost effectiveness studies are needed to validate and further analyse the results of the present study, they added.