GUEST POST: Is “sitting on your hands” an option these days for babies with bronchiolitis?

Paediatric doctors and nurses have long been dismayed that we have no useful interventions (other than supportive therapy) for babies with bronchiolitis. We have known for decades that using nebulisers, doing chest x-rays, and starting antibiotics are generally pointless for most infants with bronchiolitis – they are more likely to lead to overtreatment and harm than provide any useful benefit. The current generation of consultants, when we started as registrars, were told that most babies with bronchiolitis get better, some get worse, and the best thing to do is monitor closely, support the baby, and ‘sit on your hands’ unless you have to do something. This generally works pretty well, and we have tried to engrain this ethos in our juniors.

Every year centres around the UK do audits which show that we do too many investigations and start too many interventions, despite our guidelines telling us not to. At least, that has been the case in our centre. Our regional children’s hospital is one of the largest and busiest paediatric hospitals in Europe, and we pride ourselves on being a centre of excellence. When we audited our management of bronchiolitis we realised that maybe we weren’t being excellent – there was a disconnect between what is written in our guidelines and what was being done in practice. We, fortunately, work in a hospital in which we are able to openly question each other to learn where we are going wrong, and in an environment where we want to hear from nursing staff, parents, and junior doctors. In this blog we wanted to share an anecdote that has led to improvements in our service.

When revamping our bronchiolitis guideline our general paediatricians echoed the results of our audits – they felt we were using too many nebulisers and doing too many chest x-rays. So we asked “why are you doing these things, when you know they don’t help?”. We found that most were being done out-of-hours, so we asked the junior doctors “why are you doing these things, when you know they don’t help?”. They told us that sometimes the nursing staff were insistent that they had to do something imminently – ‘sitting on your hands’ didn’t seem like the done thing any more. So we asked the nurses “why are you doing these things, when you know they don’t help?”. They told us that parents, all night, were insisting that they should try something – sitting on your hands isn’t an option any more.

So we spoke to the parents of babies currently on the ward, who agreed that they had been pushing for interventions all night. We asked them their understanding of “supportive treatment”. Their perception was that when they came through the hospital they were told “there’s nothing you can do for bronchiolitis, and if you think they are bad now….. just wait till three days time”.

(and now … their solution … sorry for missing this earlier … Bob)

We realised that the reason we were using too many interventions was because we had been, inadvertently, disempowering parents. We have now changed the way we approach parents with bronchiolitis – we try to tell them that their baby may well get worse but there are lots of things they can do to try and ameliorate that deterioration: “pick up your baby if they are crying” (physiotherapy), “make sure people wash their hands before they examine your baby” (infection control), “monitor how much your baby is feeding and let the nurses know if you are worried” (nutrition). According to our business intelligence unit we saved hundreds of thousands of pounds in that bronchiolitis season.

I still think ‘sitting on your hands’ is the right thing to do:

‘Sitting on your hands’ involves a complex multidisciplinary approach to monitoring and managing babies

‘Sitting on your hands’ means protecting babies from harmful, useless interventions and investigations

‘Sitting on your hands’ requires an up to date understanding of current evidence, and pathophysiology, and being able to communicate that with colleagues and parents.

‘Sitting on your hands’ requires us to train and empower nursing staff to ensure they know they are central to that care.

And ‘sitting on your hands’ requires us to brave enough to draw on the skills and resources of parents. Only then will they realise how effective ‘sitting on your hands’ can be, and we can provide the supportive therapy that babies with bronchiolitis need.

Ian Sinha, consultant respiratory paediatrician, Alder Hey Children’s Hospital, Liverpool

Jennifer Holden, Advanced Nurse Practitioner, Alder Hey Children’s Hospital, Liverpool

Helen Cibinda, Senior Manager, Alder Hey Children’s Hospital, Liverpool

iansinha@liv.ac.uk, Twitter: @iansinha

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