Discharge Planning for Children With Critical Bronchiolitis

Bronchiolitis is one of the most common causes of hospital admission in infants and young toddlers.^1,2  Respiratory syncytial virus, in particular, is estimated to cause 1 in 334 hospitalizations a year in children <5 years old.²  A recent cohort study revealed that PICU admissions for bronchiolitis have increased from 2004 to 2018 with an associated increase in healthcare cost.³  The same study revealed no significant change in mortality. Despite a large and growing literature on hospitalization outcomes in bronchiolitis, there is little study of short- and long-term morbidity after a PICU hospitalization for bronchiolitis. Bronchiolitis is typically considered an acute and self-limited condition, so, the majority of research in the field has focused on hospital length of stay, resource utilization, and readmissions as the outcomes of interest.⁴  Few studies have assessed functional deficits after hospitalization, despite growing awareness of conditions like postintensive care syndrome. As PICU admissions for bronchiolitis increase and survival trends in the PICU rise, understanding the incidence and burden of ICU morbidity is crucial in caring for these patients. Pollack et al examined the development of new morbidities during PICU stays.⁵  They found that new morbidities are common and occur in both surgical and nonsurgical ICU patients. Other studies have found that new impairments after ICU hospitalization are more likely to occur in patients with younger age and more severe illness, which could possibly be extrapolated to infants with bronchiolitis.⁶  However, there is a paucity of information specific to morbidity after PICU admissions for bronchiolitis.

In their study, “Acute Neuro-Functional Morbidity Upon Discharge from the PICU after Critical Bronchiolitis,” Saju et al⁷  evaluated the incidence of acute neuro-functional morbidity (ANFM) in patients with critical bronchiolitis at PICU discharge. They reviewed medical records from their institution from 2014 to 2016 and defined ANFM as documentation at the day of discharge from the PICU of swallow difficulty, the use of nasogastric tube feeds, hypotonia, or lethargy. They found that 17% of the 417 patients included in the study met the criteria for ANFM. The authors also compared a high-risk subgroup with a low-risk group and found 47% of the high-risk compared with 12% of the low-risk patients had ANFM. Patients were considered high-risk for reasons including previous acute neurologic illness requiring hospitalization, chronic neurologic conditions such as cerebral palsy, and a history of feeding difficulty. Other identified factors associated with ANFM included preexisting conditions, young age, the need for intubation, and a longer length of stay in the PICU. Additionally, almost half of the identified morbidity persisted at hospital discharge.

The authors identify several limitations to this study. First, the data collected was limited to what was available in the electronic medical record and their internal PICU database. Therefore, the data were limited to what was previously documented and may have not fully captured the number of patients with ANFM. The authors also acknowledge that they did not assess longer-term outcomes because patients were not followed after discharge to determine if their morbidity was ongoing. Additionally, it is not clear from the study to what degree the patients were impacted by their morbidity or if they had significant functional limitations. In particular, concerns have previously been raised that dysphagia may be an area of overdiagnosis in pediatric hospital medicine; this remains a possibility in this study’s outcome given the lack of data provided about the documented swallow difficulty.^8,9  Finally, all patients with high-flow nasal cannula were cared for in the PICU at their institution. So, the study may not represent current practices because there is a national trend for high-flow nasal cannula care to be provided outside of the PICU setting.¹⁰ 

The importance of functional deficits at hospital discharge is magnified by recent work questioning the need for in-person follow-up with the primary care physician after bronchiolitis hospitalization. Although arranging hospital follow-up is typically considered a component of quality discharge planning, little research has tested that recommendation, and routine follow-up requires a time commitment from the clinician and family, parent time away from work, expenses for travel and clinic copay, and potential infectious exposures within the clinic.^11,12  Schroeder et al performed posthospital telephone follow-up with families of children recently discharged with bronchiolitis; approximately two-thirds attended a follow-up visit and were generally satisfied with the visit, citing “reassurance” as the primary benefit to their family. Of note, the plan of care changed infrequently during the follow-up visit, but new prescriptions were provided at 12% of those visits, including breathing treatments, corticosteroids, and antibiotics.¹³  These findings prompted the development of the Bronchiolitis Follow-up Intervention Trial, a randomized noninferiority clinical trial comparing as-needed with scheduled posthospitalization follow-up visits for children hospitalized with bronchiolitis.¹⁴  As-needed follow-up was found to be noninferior to scheduled follow-up for parental anxiety, the primary outcome, and multiple secondary outcomes, including hospital readmission. Children requiring care in the PICU represented 28% of enrolled patients in that study, although many children with underlying medical complexity were excluded. Of note, this study captured hospital readmissions for any cause before resolution of bronchiolitis symptoms, so, presumably, this would include issues like aspiration pneumonia secondary to dysphagia, although it was not designed to assess that outcome specifically. As more clinicians become aware of this literature, it is possible that fewer patients with bronchiolitis will be referred to the primary care physician at hospital discharge, which could have implications for patients with new functional morbidity secondary to their hospitalization. One strategy to optimize posthospitalization referrals for those patients most at risk is proposed by Williams et al¹⁵  in this issue. Post-ICU follow-up programs could offer increased oversight of those children at higher risk for new morbidity while minimizing follow-up needs for children with a less complicated hospitalization.

Trends of increasing ICU utilization for bronchiolitis but decreasing primary care follow-up necessitate an improved understanding of these patients’ morbidity at hospital discharge. Important next steps include a more specific characterization of the deficits described by Saju et al,⁷  including both the degree and persistence of morbidity over time. Additional investigation of risk factors associated with posthospitalization morbidity will promote improved referral processes at discharge, optimizing the balance between patient care, safety, and resource utilization. Additionally, future study designs should consider specifically assessing posthospitalization outcomes in these patients, including short-term vulnerabilities after hospitalization and the utility and outcomes of hospital follow-up visits for different populations.