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)
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
firstname.lastname@example.org, Twitter: @iansinha