Pediatric Physicians React to Bronchiolitis Clinical Practice Guideline

But the fact remains that PHM thought leaders, despite their best intentions and dedicated pursuit of research to improve bronchiolitis outcomes, have begun to alienate peds ED physicians and likely many pediatric hospitalists as well. In the Country of (Todd) Florin, MD, MSCE, otherwise known as Cincinnati Children’s Hospital ED, researchers led by Dr. Florin found that the release of the AAP bronchiolitis CPG in 2006 had not significantly changed the utilization of nonrecommended resources in bronchiolitis, despite the fact that use of these nonrecommended resources only increased length of stay without reducing readmission rates.⁴ Once again, we find that simply releasing high-minded CPGs without appropriate local multidisciplinary active implementation is as ill-fated as a land war in Asia.

Perhaps we shouldn’t be surprised that individuals trained for years to trust their gut feelings about the patient in front of them would begin to buck the tidal wave of regulation, oversight, and standardization that has begun to define how medicine is practiced in the 21st century. Many pediatric hospitalists and pediatric ED physicians would take issue with the outcomes cited by CPGs as not taking into account the therapeutic benefit of even short-term symptomatic improvements achieved through bronchodilators use. As Dr. Inigo Montoya might say, doctors have been in the thinking-independently business so long that, now that it’s over, they don’t know what to do with the rest of their lives.

Yet, is that really true? Have clinical pathways, practice guidelines, and high-minded academic pediatric hospitalists snuffed the life out of our quick-thinking, sword-wielding heroic physician?

Perhaps, but mostly dead is slightly alive.

I would posit, however, that our heroic physician, instead of viewing the local hospital’s creator of CPGs and clinical pathways as a condescending Prince Humperdinck, should consider him more of a Fezzik, who would do their heavy lifting for more mundane tasks, leading the charge against more worthy adversaries. Who wants to enter all those orders anyway?

For who could resist storming the castle of Kawasaki Disease? Hand-to-hand combat with metabolic defects? The Fire Swamp of PHM is still lurking with Diseases of Unusual Size that haven’t been tamed by AAP CPGs. Even our old nemesis, sepsis, has been found to be less susceptible to the arrows of early goal-directed therapy (EGDT) than we thought.⁵ By reporting in the October 16, 2014, issue of New England Journal of Medicine that EGDT may not reduce mortality in sepsis after all, fearless Aussie and Kiwi ARISE investigators may have opened a path for pediatric hospitalists and intensivists to follow in the battle against pediatric sepsis.

So, fear not, brave PHM warrior. There are still dragons to slay, ogres to battle, ED docs to debate as to whether to admit the kid with iocane poisoning. Do not worry about CPGs, and have fun storming the castle!

I would like to thank Drs. Scott Krugman, Jay Fisher, and Todd Zimmerman for giving their permission to reproduce their listserv posts, which inspired this column.

Dr. Chang is pediatric editor of The Hospitalist. He is associate clinical professor of medicine and pediatrics at the University of California at San Diego (UCSD) School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital. Send comments and questions to [email protected].

References

1. Ralston SL, Lieberthal AS, Meissner HC, et al. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics. 2014;134(5):e1474-e1502.
2. Mittal V, Hall M, Morse R, et al. Impact of inpatient bronchiolitis clinical practice guideline implementation on testing and treatment. J Pediatrics. 2014;165(3):570-576.e3.
3. Mittal V, Darnell C, Walsh B, et al. Inpatient bronchiolitis guideline implementation and resource utilization. Pediatrics. 2014;133(3):e730-737.
4. Florin TA, Byczkowski T, Ruddy RM, Zorc JJ, Test M, Shah SS. Variation in the management of infants hospitalized for bronchiolitis persists after the 2006 American Academy of Pediatrics bronchiolitis guidelines. J Pediatrics. 2014;165(4):786-792.e1.
5. ARISE Investigators, ANZICS Clinical Trials Group, Peake SL, et al. Goal-directed resuscitation for patients with early septic shock. New Engl J Med. 2014;371(16):1496-1506.