Bronchiolitis Care Map Go directly to Care Map Flowchart How to Use Reference Icons Go directly to Care Map Flowchart When accessing a document, please use the browser return arrow (upper left-hand corner) to return to the Care Map Care Map Symbols Source Reference Links to more Start of a Care information or returns Education Module Map Segment to a previous page. Hospital Policy Decision Stop and Point Evaluate Hospital Reference Provider Information Care Map Step Progression of Blue underlined text care – Patient Download File is a hyperlink Improving For questions concerning this care map, contact: [email protected] 2 Last Update: 1/18/16 Bronchiolitis Care Map Quick Overview: Bronchiolitis Epidemiology, The Evolution of Bronchiolitis Go directly to Care Map Flowchart Pathophysiology, and Treatment Care at ETCH (2007-2014) Suggested Inclusion Criteria for Bronchiolitis Care Map This care map document does not supersede the clinical judgment of a provider regarding the care that is ultimately • Age <48 months with peak age range 3-6 ordered for a given patient. Click to see full disclaimer. months. • A constellation of clinical signs and symptoms occurring in children typically younger than 2 years, including a viral upper respiratory tract prodrome followed by Executive Summary increased respiratory effort and wheezing. Clinical signs and symptoms of bronchiolitis consist of rhinorrhea, cough, tachypnea,wheezing, crackles, and increased respiratory effort manifested as American Academy of Pediatrics 2014 Bronchiolitis grunting, nasal flaring, and intercostal Treatment Guidelines and/or subcostal retractions. • Risk factors for severe disease which include a history of prematurity, age <12 weeks, underlying cardiopulmonary disease, or Why does ETCH include patients ages 24-48 months in immunodeficiency should be assessed. our Care Map when most hospitals would not? For questions concerning this care map, contact: [email protected] 3 Last Update: 1/18/16 Bronchiolitis Care Map Quick Overview: Bronchiolitis Epidemiology, The Evolution of Bronchiolitis Go directly to Care Map Flowchart Pathophysiology, and Treatment Care at ETCH (2007-2014) This care map document does not supersede the clinical judgment of a provider regarding the care that is ultimately ordered for a given patient. Click to see full disclaimer. Potential Reasons to Avoid Bronchiolitis Care Map Executive Summary • Cardiac disease requiring baseline medication • Anatomic airway abnormalities American Academy of Pediatrics 2014 Bronchiolitis • Neurologic disease processes Treatment Guidelines • Immunodeficiency • Chronic lung disease Why does ETCH include patients ages 24-48 months in our Care Map when most hospitals would not? For questions concerning this care map, contact: [email protected] 4 Last Update: 1/18/16 The Bronchiolitis Respiratory Scoring Grid • This grid is a tool used to help determine the airway care a bronchiolitis patient receives while at ETCH. • The original grid has been modified for use at ETCH to include RR values for patients in the 2-4 year age range. • The grid is used by RC for patients they treat in both the ED and on the general care floors. • The grid is not used by RN’s in the ED to assess patients for treatment. • The grid is used by RN’s for all bronchiolitis patients admitted to the floors. • All patients are to be scored every assessment visit, and re- scored after any airway intervention has been performed. Example: How to use the scoring grid. Original grid sourced from: Inter-Observer Agreement Between Physicians, Nurses, and Respiratory Therapists for Respiratory Clinical Evaluation in Bronchiolitis. V. Gajdos, L. Beydon, B.Pellegrino, L. de Pontual, S. Bailleux, P. LaBrune, J. Bouyer. Pediatric Pulmonology. 44:754-762, 2009. For questions concerning this care map, contact: [email protected] 5 Last Update: 1/18/16 Emergency Department Care: Chief Complaint = Respiratory/Wheezing <4 years (Registration & Triage) *ESI = Emergency Severity Index Registration Preliminary ESI* level assigned before triage. ESI = ONE ESI* 3 = Triage in order of arrival Request • ESI* ESI* 2 = Triage next immediate Diagnostic testing • Level • ESI* ONE = Immediate treatment required provider & therapies not evaluation. routinely ESI = 2 or 3 recommended: • Albuterol Triage • Racemic Epi • Obtain vital signs & pox • Hypertonic Saline • Perform respiratory assessment (ED) • Reassess ESI level • Hypertonic Saline • RN Initiates appropriate ED Standing Order (In-Pt) Set per patient age, if indicated. • Corticosteroids • Chest Physiotherapy Treat per ED Continue to • Nasopharyngeal 12-48 Wheezing 1-4 Care ED Wheezing 1- Suction months Pt. Map 4 Protocol • Singulair age • Antibiotics CareMap • Chest X-rays • Routine viral <12 testing months Treat per ED Wheezing <1 Care Map Continue to next page For questions concerning this care map, contact: [email protected] 6 Last Update: 1/18/16 Emergency Department Care: ED Wheezing <1 Year Care Map Continued from previous page Admit Patient to ED Pod/Room *ESI = Emergency Severity Index Diagnostic testing • BBG or bulb suctioning by assigned RN or ED & therapies not Tech if nasal congestion indicates. • RN reassessment of patient post-suction. routinely Request • If pox sat <90%, begin O2 per NC or other ESI* ESI = ONE immediate recommended: appropriate device; titrate as needed. Level provider • Albuterol • Reassess assigned ESI* level. evaluation. • Racemic Epi • Inform provider if O2 required. • Hypertonic Saline • Await provider evaluation. (ED) ESI = 2 or 3 • Hypertonic Saline (In-Pt) • Corticosteroids Provider evaluates for admission, discharge, • Chest or additional treatment. Discharge Physiotherapy Admit or • Nasopharyngeal Discharge Suction Discharge • Singulair Admit home: with • Antibiotics suction bulb • Chest X-rays Admit to floors if: & care Admit to PICU if: • Routine viral • Dehydration needing IV instructions. • Apnea present testing • Inability to bottle/feed • Toxic appearance • O2 sats OK on <50% FIO2 • FIO2 > 50% • HFNC initiated with • Pt. requires HFNC improvement after 2 hours • Hx of lung dz/cardiac dz in ED For questions concerning this care map, contact: [email protected] 7 Last Update: 1/18/16 Emergency Department Care: ED Wheezing 1-4 Years Care Map *ESI = Emergency Severity Index Continued from ED Registration And Triage page ESI* ESI = One Level Perform respiratory specific • Provider to evaluate. assessment & reassess ESI* level. ESI = 2 or 3 • Consider HFNC trial. If Diagnostic testing starting HFNC: & therapies not . Obtain IV access • BBG suctioning by RN or RC if nasal congestion routinely present or suspected. NPO . Obtain CBG recommended: • Begin O2 if Spo2 <90%. Titrate liter flow as • Albuterol needed. • Racemic Epi • Pre/Post grid scores to be obtained by RC. Discharge Home with: • Hypertonic Saline •Bulb suction & instruct (ED) •MDI/spacer or home neb instruct, as needed • Hypertonic Saline Score Score Score (In-Pt) <4 4-6 7-9 Admit to floors if: • Corticosteroids • Dehydration needing IV • Chest • Inability to bottle/feed Physiotherapy • O2 sats OK on <50% FIO2 Trial of 4 puffs albuterol HFA • Nasopharyngeal Score • HFNC initiated with Suction 90mcg/puff with mask/spacer, or improved No improvement after 2 hours in 2.5 mg nebulized. (Xopenex post- ED • Singulair treatment • (Admit as bronchiolitis or VLRI, • Antibiotics substitution criteria) ? Yes based on response to • Chest X-rays bronchodilators, if admin.) Await provider evaluation. • Routine viral • Continue albuterol per testing • Admit to PICU if: provider orders • Apnea present • Toxic appearance Await Provider to evaluate for • FIO2 > 50% provider admission/discharge. • Pt. requires HFNC evaluation Criteria • Hx of lung dz/cardiac dz For questions concerning this care map, contact: [email protected] 8 Last Update: 1/18/16 Medical Floor Initial Care: Bronchiolitis & VLRI Order Sets Pt. admitted on either Admission Order Set: Bronchiolitis Care Bronchiolitis or VLRI order set Map Admission Order Set: Viral Lower Diagnostic testing • Explain details of care plan & pox tips to family. Respiratory Illness (VLRI) Care Map & therapies not • Suction/Score/Suction by either/both RN/RC routinely Q2H, or @ initial freq. ordered by provider. Quick Reference: Guidelines for recommended: • Continuous Pox for first 24-hours of admit. Weaning of RC Assessments to Q-shift Consider need for IV fluids if RR consistently >60 • Albuterol • RC & RN to consider weaning of assessment/sxn • Racemic Epi • freq. per weaning policy guidelines if grid scores Quick Reference for RNs’ floating to the • Hypertonic Saline are < 4. (RN assessment freq. may not wean to Medical floors: An RSV Survival Packet (ED) greater than Q4H. RC assessments may be • Hypertonic Saline weaned out to Q12H per weaning policy (In-Pt) Escalation of Care guidelines, if pt scores and condition allow.) • Corticosteroids Call provider to evaluate if pt. Wean O2 if Pox >90% awake, or >88% sleeping. • • Chest • condition &/or scores are Physiotherapy worsening. (Consider need for • Nasopharyngeal Rapid Response Team. Call ext. Suction 8911) • Singulair Patient • NP suction X1, but only if pt’s WOB • Antibiotics improving not improving with BBG suction. No • Chest X-rays and/or • If bronchiolitis admission, may • Routine viral stable with consider trial of racemic epi (with testing score < 6 MD approval) for scores > 4. • If VLRI admission, may consider trial of ordered PRN aerosol for Yes scores >4. • Consider High Frequency Nasal Continue to next page Cannula trial.