As Christmas approaches I still cannot get used to it in the southern hemisphere. Coming from England I am used to a cold, dark, and often wet, festive season, with its attendant medical problems. I was reminded of this whilst listening to the latest podcast from Ken Milne and the Skeptics Guide to Emergency Medicine.
Ken and his guest skeptic, Chris Bond, took a critical look at this paper, and were joined in discussion by the author Amy Plint.
Plint, A.C., Taljaard, M., McGahern, C., Scott, S.D., Grimshaw, J.M., Klassen, T.P. and Johnson, D.W. (2016) ‘Management of Bronchiolitis in Community Hospitals in Ontario: a Multicentre Cohorhttps://www.aap.org/en-us/Documents/quality_bqip_pediatrics.pdft Study’, CJEM, 18(6), pp. 443–452. doi: 10.1017/cem.2016.7.
Key secondary outcomes
- 80% of children received bronchodilators in the ED and 45% received them on discharge
- 31% of children received steroids in the ED and 24% on discharge
- 5% received antibiotics in the ED and 13% on discharge
- 55% of children received a chest x-ray
- 23% had a nasopharyngeal swab
- 7% had blood tests
Bronchiolitis is one of the most common causes of presentation to the emergency department and accounts for around 2% of all paediatric admissions. But I don’t want to concentrate on the management of bronchiolitis here – take a look at Henry’s post here or listen to the smooth Tim Horeczko for the latest – I want to consider why there is such a deviation between what we would consider standard practice and actual practice.
The study was carried out in mixed community emergency departments, staffed by generalists rather than trained paediatric emergency practitioners. Some of the sites only recruited 2 patients and so it is understandable that they might not be up to date with current recommendations. The major factor that lessens the external validity of this study is the that the data was based on presentations between the 2005 and 2007 bronchiolitis seasons. Hopefully there has been an increased uptake of clinical guidelines since then.
Cabana et al. identified a number of factors affecting adherence to clinical practice guidelines. They break down to those related to either physician attitudes, physician knowledge or behaviours.
- Not agreeing with specific guidelines e.g. interpretation of the evidence
- Not agreeing with guidelines in general
- Lack of motivation
- Lack of familiarity perhaps due to amount of knowledge available or lack of access
- Lack of awareness associated with time needed to stay up to date
- Patient factors such as problems reconciling patient preferences with guidelines
- Guideline factors such as the presence of contradictory guidelines
- Environmental factors such as a lack of time or resources
Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA, Rubin HR. Why don’t physicians follow clinical practice guidelines?: A framework for improvement. Jama. 1999 Oct 20;282(15):1458-65.
Lenzer J. Why we can’t trust clinical guidelines. BMJ. 2013 Jun 14;346(58):f3830.
Fryar C. Doctors can depart from guidelines in patients’ best interests. BMJ. 2015 Feb 18;350:h841.
Lenzer J, Hoffman JR, Furberg CD, Ioannidis JP, Guideline Panel Review Working Group. Ensuring the integrity of clinical practice guidelines: a tool for protecting patients. BMJ. 2013 Sep 17;347:f5535.
Jenco M. QI project decreases unnecessary care for bronchiolitis.
Korppi M. What are evidence‐based guidelines and what are they not?. Acta Paediatrica. 2016 Jan 1;105(1):11-2.
Ralston SL, Garber MD, Rice-Conboy E, Mussman GM, Shadman KA, Walley SC, Nichols E. A multicenter collaborative to reduce unnecessary care in inpatient bronchiolitis. Pediatrics. 2016 Jan 1;137(1):e20150851.