OBJECTIVES:

To analyze the impact of an integrated care pathway on reducing unnecessary treatments for acute bronchiolitis.

METHODS:

We implemented an evidence-based integrated care pathway in primary care (PC) centers and the referral emergency department (ED). This is the third quality improvement cycle in the management of acute bronchiolitis implemented by our research team. Family and provider experiences were incorporated by using design thinking methodology. A multifaceted plan that included several quality improvement initiatives was adopted to reduce unnecessary treatments. The primary outcome was the percentage of infants prescribed salbutamol. Secondary outcomes were prescribing rates of other medications. The main control measures were hospitalization and unscheduled return rates. Salbutamol prescribing rate data were plotted on run charts.

RESULTS:

We included 1768 ED and 1092 PC visits, of which 913 (51.4%) ED visits and 558 (51.1%) PC visits occurred in the postintervention period. Salbutamol use decreased from 7.7% (interquartile range [IQR] 2.8–21.4) to 0% (IQR 0–1.9) in the ED and from 14.1% (IQR 5.8–21.6) to 5% (IQR 2.7–8) in PC centers. In the ED, the overall epinephrine use rate fell from 9% (95% confidence interval [CI], 7.2–11.1) to 4.6% (95% CI, 3.4–6.1) (P < .001). In PC centers, overall corticosteroid and antibiotic prescribing rates fell from 3.5% (95% CI, 2.2–5.4) to 1.1% (95% CI, 0.4–2.3) (P =.007) and from 9.5% (95% CI; 7.3–12.3) to 1.7% (95% CI, 0.9–7.3) (P <.001), respectively. No significant variations were noted in control measures.

CONCLUSIONS:

An integrated clinical pathway that incorporates the experiences of families and clinicians decreased the use of medications in the management of bronchiolitis.

Acute bronchiolitis (AB) is the most common reason for hospital admission in infants <1 year of age1  worldwide. Although evidence-based guidelines recommend primarily supportive care,2,3  many unnecessary treatments remain well documented and contribute to a care quality problem of overtreatment.4,5  In addition, despite the high incidence, increasing morbidity, and significant economic impact of AB, there is still great variability in clinical practice, both in the diagnosis and management of this illness.68 

Quality improvement (QI) initiatives implemented in response to overtreatment problems have been shown to decrease the use of non–evidence-based treatments and testing and also provide achievable benchmarks of care for clinical quality indicators, especially in hospital settings.912  For example, 2 studies conducted by our research team between 2016 and 20187,13  revealed that the QI cycles were successful in reducing the use of pharmacotherapy in AB in the emergency department (ED) and primary care (PC) centers. The main interventions in those QI cycles were the distribution of an evidence-based protocol and informative posters, the development of monthly interactive sessions with online data collection and feedback, and the sending to pediatricians of weekly reports on their bronchodilator prescribing.

Involving patients and their families in quality teams seems to be a promising approach, but the conditions for and effects of this involvement have yet to be properly evaluated.14,15  Our hypothesis was that an improvement initiative that incorporates the experiences of families and providers could facilitate adherence to the recommendations of good clinical practice. The objective of the study was to analyze the impact of an integrated care pathway, built on previous QI initiatives, that incorporates family and provider experiences on adherence to recommended management practices for AB.

We conducted a QI initiative, evaluating the use of pharmacotherapies observed in the management of children diagnosed with bronchiolitis in 2 health districts and the referral pediatric ED. This is the third QI cycle in the management of AB implemented by our research team. The 2 previous QI cycles took place in the 2016–2017 and 2017–2018 AB seasons; the first one was conducted in PC centers,7  and the second one incorporated the referral ED.13 

Our health care system provides comprehensive, free, and universal coverage. In the 2 health districts, there are 20 PC centers with 39 pediatricians who care for 36 412 children, of whom 6371 (17.5%) are infants <2 years old. The region where the study was conducted has 2 other health districts with 30 PC centers, where none of the interventions under study were performed.

The referral pediatric ED is located in a tertiary acute care teaching hospital near Bilbao, in the Basque Country, Spain. This department provides care to children <14 years old, with a mean of 60 000 emergency visits a year. Approximately 2% of these visits are due to AB. There is an observation unit in the ED, which is a 24-hour unit with 10 beds and is staffed by pediatric emergency physicians.

We executed this QI initiative over the 2018–2019 AB season (October 2018 to March 2019). All children <2 years old with a diagnosis of bronchiolitis, defined as the first presentation with a viral respiratory tract infection with respiratory distress,16  were included, regardless of whether they had comorbidities (lung or congenital heart disease, immunodeficiency, or neuromuscular, neurologic, or genetic disease). The exclusion criterion was a previous diagnosis of bronchiolitis ≥1 month before the index episode.

We assembled a 25-person multidisciplinary team that consisted of pediatric PC physicians, pediatric emergency physicians, pediatric residents, pediatric nurses, nurses’ aides, clinical epidemiologists, and health care quality experts.

After the 2017–2018 AB season, one group workshop was held with parents of infants who had been diagnosed with bronchiolitis, and another was held with providers involved in the management of the disease (Supplemental Fig 6). A design thinking approach was used for the development of these workshops.

  • Families: Using a patient journey map17,18  designed for AB, families highlighted the points that they considered most important in their experience with AB. The patient journey map for AB is an overview of the different steps experienced (symptom onset at home, at the PC center. and/or at the ED-follow-up and closing of the episode) by patients during a health care process. We analyzed the following at every step: interactions (eg, in the ED setting, triage, and medical care), expectations, nature of the experience (positive or negative), magnitude of the interaction (low, medium, or high), human actors (partner, friend, nurse, doctor, etc) and initiatives to improve the patient and family experience (Supplemental Fig 7).

  • Providers: In the workshop with health care providers, using a focus-group methodology,19  the providers considered the recommended clinical practice and the protocol for the management of AB: diagnostic criteria and recommendations for the assessment, coding, and registration of severity; avoiding the use of unnecessary pharmacotherapy; and giving standardized information to families. The participants were also invited to discuss the main barriers to implementing the currently recommended care for AB in their clinical practice.

The most important conclusions of these 2 workshops are summarized in Fig 1.

FIGURE 1

Main conclusions drawn from the workshops conducted with families and providers.

FIGURE 1

Main conclusions drawn from the workshops conducted with families and providers.

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A kickoff meeting was convened to review the results of the improvement initiatives conducted in previous bronchiolitis seasons and to develop new interventions while taking into account the observations made in the group workshops with families and providers. A multifaceted plan was developed and implemented to increase compliance with the bronchiolitis integrated care pathway (BICP) and to reduce unnecessary treatments in the PC center and the referral ED (Fig 2):

  • dissemination by e-mail to pediatricians of the links to the BICP, highlighting the core features of the protocol for the management of the AB;

  • holding of regular information-training sessions, including review of the currently available evidence on the management of AB and provision of data related to incidence and management of AB in each PC center and the ED;

  • inclusion in the organization’s computer program of a pop-up window associated with the diagnosis of AB that automatically displays the most important documents associated with the pathway, including the decision tree, information sheets for parents, and severity score;

  • display of posters with the decision tree, key documents, and a summary of the BICP;

  • distribution of badges for uniforms with the slogan for the epidemic: “Team on the Pathway”;

  • distribution of paper information sheets for parents;

  • provision of information about the disease and preventive measures to parents at scheduled health checkups in their children’s first year of life;

  • provision of training for families in nasal suctioning during PC and ED consultations;

  • development of the eSano web page, which includes all the AB pathway tools as well as educational videos for parents (https://www.osieec.eus/esano/);

  • dissemination by e-mail to pediatricians of feedback on levels of and/or improvement in pharmacologic prescribing and of regular literature reviews with relevant articles on AB management;

  • display of an educational poster in waiting and consultation rooms with key messages for families;

  • display of an informative poster in the lobby of the hospital during AB seasons; and

  • campaigns on social media with educational messages targeting families drafted by the health care professionals themselves.

FIGURE 2

Key driver diagram. This tool displays the primary driver (center) or system factors affecting the project outcome listed in the aim (left). The interventions that were employed to address each primary driver are shown (right).

FIGURE 2

Key driver diagram. This tool displays the primary driver (center) or system factors affecting the project outcome listed in the aim (left). The interventions that were employed to address each primary driver are shown (right).

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Both the BICP and the tools necessary for its implementation, as well as training and information materials for providers and families, were available at the beginning of the intervention AB season.

A computerized search tool was used to identify patients with International Classification of Diseases, Ninth Revision or International Classification of Diseases, 10th Revision codes related to bronchiolitis in their health record for the period of data collection. Demographic and clinical and medical prescribing data were collected from the computerized database system of the Basque Health Service. The study was approved by the Ethics Committee of the Basque Country. Informed consent from parents was not considered necessary because the children did not undergo any interventions related to this study and data were handled anonymously.

The primary outcome measure was the percentage of infants with AB receiving salbutamol, in terms of its rate of use in the ED and rate of prescribing in PC centers in this population.

Secondary outcomes evaluated included the following:

  • the rate of infants with AB receiving epinephrine, antibiotics, and corticosteroids in the ED; and

  • the rates of antibiotic and corticosteroid prescribing in PC centers.

To evaluate the possible unintended consequences of decreasing interventions, we studied several balance outcome measures, defined as follows:

  • balance measure 1: overall rate of hospital admission;

  • balance measure 2: rate of PICU admission;

  • balance measure 3: length of stay in the ED;

  • balance measure 4: rate of unscheduled returns within 72 hours; and

  • balance measure 5: rate of unscheduled returns with admission within 72 hours.

To address the issue of secular trends during our project, we also obtained the rate of salbutamol prescribing in the EDs and PC centers of the Basque Health Service in districts where the BICP was not implemented. Finally, to evaluate the impact of the educational videos and messages aimed at families, we recorded the number of visits and interactions on Facebook, Twitter, and YouTube during our social media campaign.

We compared performance over the 2018–2019 AB season to performance over the previous 2017–2018 AB season. Run charts20  were used to evaluate outcome measures over the 2 seasons. On each run chart, the outcome of interest was plotted on the vertical axis against time on the horizontal axis. Each data point represents 15 days of data, and data from outside the bronchiolitis season were not included in the analysis. The timing of each intervention is indicated on the charts.

Quantitative data were expressed as means and SDs or medians and interquartile ranges (IQRs), depending on the distribution of the variables, and categorical data were expressed as frequencies and percentages. The quantitative variables were compared between the 2 seasons by using the χ2 test with the level of statistical significance set at P < .05. Statistical analyses were performed by using IBM SPSS Statistics for Windows (version 23; IBM SPSS Statistics, IBM Corporation). and Stata 16 for Windows (Stata Corp, College Station, TX).

During the study period, 1768 episodes of AB were recorded in the ED (855 in the 2017–2018 AB season and 913 in the 2018–2019 AB season) and 1092 episodes of AB were recorded in PC centers participating in the initiative (534 in the 2017–2018 AB season and 558 in the 2018–2019 AB season). Among the patients seen in the ED, 333 (38.9%) in the 2017–2018 AB season and 402 (44%) in the 2018–2019 AB season (P = .03) came from the PC centers where the interventions were performed.

Analyzing run charts, we found that salbutamol use decreased from 7.7% (IQR 2.8–21.4) to 0% (IQR 0–1.9) in the ED (Fig 3) and from 14.1% (IQR 5.8–21.6) to 5% (IQR 2.7–8) in PC centers (Fig 4).

FIGURE 3

Run chart revealing a decrease in the percentage of infants receiving salbutamol in the ED after implementation of the BICP.

FIGURE 3

Run chart revealing a decrease in the percentage of infants receiving salbutamol in the ED after implementation of the BICP.

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FIGURE 4

Run chart revealing a decrease in the percentage of infants prescribed salbutamol in the PC settings after implementation of the BICP.

FIGURE 4

Run chart revealing a decrease in the percentage of infants prescribed salbutamol in the PC settings after implementation of the BICP.

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In the ED, when measured over the whole winter, salbutamol and epinephrine use decreased from 9.1% (95% confidence interval [CI], 7.3–11.2) to 0.9% (95% CI, 0.5–1.8) (P < .001) and from 9% (95% CI, 7.2–11.1) to 4.6% (95% CI, 3.4–6.1) (P < .001), respectively. The use of antibiotics did not vary significantly (3.1%; 95% CI, 2.1–4.5 vs 1.7%; 95% CI, 1.0–2.8; P = .06). The rate of corticosteroid use was <0.5% in both AB seasons (Table 1).

TABLE 1

Comparison of Outcome Measures for Episodes Seen in the ED and in the PC Centers Where the QI Initiative Was Conducted in the Pre- and Postintervention AB Seasons

2017–2018 AB Season2018–2019 AB SeasonP
Patients seen in the ED, n 855 913 — 
 Salbutamol administered, n; % (95% CI) 78; 9.1 (7.3–11.2) 9; 0.9 (0.5–1.8) <.001 
 Salbutamol prescribed at discharge, n; % (95% CI) 34; 3.9 (2.8–5.5) 2; 0.2 (0–0.8) <.001 
 Epinephrine administered, n; % (95% CI) 77; 9 (7.2–11.1) 42; 4.6 (3.4–6.1) <.001 
Patients seen in PC centers, n 534 558 — 
 Salbutamol prescribed, n; % (95% CI) 85; 15.9 (13.6–19.2) 29; 5.2 (3.6–7.3) <.001 
 Antibiotics prescribed, n; % (95% CI) 51; 9.5 (7.3–12.3) 10; 1.7 (0.9–3.2) <.001 
 Corticosteroids prescribed, n; % (95% CI) 19; 3.5 (2.2–5.4) 6; 1.1 (0.4–2.3) .007 
2017–2018 AB Season2018–2019 AB SeasonP
Patients seen in the ED, n 855 913 — 
 Salbutamol administered, n; % (95% CI) 78; 9.1 (7.3–11.2) 9; 0.9 (0.5–1.8) <.001 
 Salbutamol prescribed at discharge, n; % (95% CI) 34; 3.9 (2.8–5.5) 2; 0.2 (0–0.8) <.001 
 Epinephrine administered, n; % (95% CI) 77; 9 (7.2–11.1) 42; 4.6 (3.4–6.1) <.001 
Patients seen in PC centers, n 534 558 — 
 Salbutamol prescribed, n; % (95% CI) 85; 15.9 (13.6–19.2) 29; 5.2 (3.6–7.3) <.001 
 Antibiotics prescribed, n; % (95% CI) 51; 9.5 (7.3–12.3) 10; 1.7 (0.9–3.2) <.001 
 Corticosteroids prescribed, n; % (95% CI) 19; 3.5 (2.2–5.4) 6; 1.1 (0.4–2.3) .007 

—, not applicable.

In PC centers, when measured over the whole winter, salbutamol, corticosteroid, and antibiotic use decreased from 15.9% (95% CI, 13.6–19.2) to 5.2% (95% CI, 3.6–7.3) (P < .001) (Fig 4), from 3.5% (95% CI, 2.2–5.4) to 1.1% (95% CI, 0.4–2.3) (P = .007), and from 9.5% (95% CI, 7.3–12.3) to 1.7% (95% CI, 0.9–3.2) (P < .001) (Table 1), respectively. Rates of salbutamol prescribing in the pre- and postintervention periods, depending on age and acuity level at ED triage, are shown in Supplemental Table 3.

A total of 4400 and 4354 episodes in PC centers and 1974 and 1870 episodes in the EDs were diagnosed as AB in the PC centers in the 11 health districts where no related interventions were performed in the 2017–2018 and 2018–2019 seasons, respectively. The overall salbutamol rates in these EDs and PC centers in both AB seasons were significantly higher than those observed in the EDs and PC centers from the districts where the BICP was implemented. The salbutamol prescribing rates in each of the EDs and PC centers in both AB seasons are shown in Fig 5.

FIGURE 5

Salbutamol prescribing rates in each of the EDs and PC districts of the Basque Health Service in both AB seasons. Overall salbutamol prescribing rates were significantly higher in the EDs and the PC districts where the BICP was not implemented. A, EDs. B, PC districts.

FIGURE 5

Salbutamol prescribing rates in each of the EDs and PC districts of the Basque Health Service in both AB seasons. Overall salbutamol prescribing rates were significantly higher in the EDs and the PC districts where the BICP was not implemented. A, EDs. B, PC districts.

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In brief, there were no changes in the overall rates of hospitalization, PICU admission, revisits, or readmissions or in length of stay in the ED after the interventions (Table 2).

TABLE 2

Acuity Level at ED Arrival and Balance Measures for Episodes Seen in the ED in the 2 AB Seasons

2017–2018 Season2018–2019 SeasonP
Total population of patients seen in the ED, n 855 912 — 
 Age, mean (SD), mo 6.4 (4.5) 6.3 (4.9) .65 
 Acuity level I–II, n (%) 58 (6.7) 72 (7.9) .41 
 Acuity level III, n (%) 575 (67.2) 616 (67.4) .91 
 Length of stay, mean (SD), min 223.6 (326.1) 233.3 (342.7) .45 
 Hospitalization rate, n (%) 114 (13.3) 125 (13.7) .87 
 ICU admission rate, n (%) 43 (5) 45 (4.9) .92 
 ED revisits, n (%) 140 (16.3) 172 (18.8) .19 
 Revisits with admission, n (%) 25 (2.9) 40 (4.3) .13 
Patients seen in the ED from PC centers where QI initiative was conducted, n 333 402 — 
 Age, mean (SD), mo 6.3 (4.5) 7.0 (5.4) .05 
 Acuity level I–II, n (%) 22 (6.6) 26 (6.4) .93 
 Acuity level III, n (%) 222 (66.6) 271 (67.4) .91 
 Length of stay, mean, (SD), min 208 (302.9) 238.1 (384) .24 
 Hospitalization rate, n (%) 36 (10.8) 56 (13.9) .24 
 ICU admission rate, n (%) 12 (3.6) 13 (3.2) .94 
 ED revisits, n (%) 54 (16.1) 67 (16.6) .94 
 Revisits with admission, n (%) 10 (2.9) 16 (3.9) .60 
2017–2018 Season2018–2019 SeasonP
Total population of patients seen in the ED, n 855 912 — 
 Age, mean (SD), mo 6.4 (4.5) 6.3 (4.9) .65 
 Acuity level I–II, n (%) 58 (6.7) 72 (7.9) .41 
 Acuity level III, n (%) 575 (67.2) 616 (67.4) .91 
 Length of stay, mean (SD), min 223.6 (326.1) 233.3 (342.7) .45 
 Hospitalization rate, n (%) 114 (13.3) 125 (13.7) .87 
 ICU admission rate, n (%) 43 (5) 45 (4.9) .92 
 ED revisits, n (%) 140 (16.3) 172 (18.8) .19 
 Revisits with admission, n (%) 25 (2.9) 40 (4.3) .13 
Patients seen in the ED from PC centers where QI initiative was conducted, n 333 402 — 
 Age, mean (SD), mo 6.3 (4.5) 7.0 (5.4) .05 
 Acuity level I–II, n (%) 22 (6.6) 26 (6.4) .93 
 Acuity level III, n (%) 222 (66.6) 271 (67.4) .91 
 Length of stay, mean, (SD), min 208 (302.9) 238.1 (384) .24 
 Hospitalization rate, n (%) 36 (10.8) 56 (13.9) .24 
 ICU admission rate, n (%) 12 (3.6) 13 (3.2) .94 
 ED revisits, n (%) 54 (16.1) 67 (16.6) .94 
 Revisits with admission, n (%) 10 (2.9) 16 (3.9) .60 

Data from the total number of episodes and episodes from the PC settings where the QI initiative was conducted are shown separately. —, not applicable.

The information campaign on our social networks were focused on the period from November 5, 2018, to December 10, 2018. We posted 15 messages on Facebook, 17 tweets on Twitter, and 10 videos on YouTube. A total of 45 883 and 12 802 visits and 4842 and 543 interactions were recorded on Facebook and Twitter, respectively. The educational videos had 3319 views.

We found that using a multisite and multidisciplinary team approach to develop a standardized clinical pathway can result in reduced use of pharmacotherapy in children seen in PC centers and the ED for bronchiolitis without unintended consequences, such as increases in rates of hospitalization, ED revisits, or readmissions or escalation of care (in particular, admission to the PICU). Our approach included tools and interventions not previously described in published bronchiolitis QI studies.1922 

Previous studies have revealed the usefulness of implementing QI measures at a local level or with collaboration between different settings to improve the management of AB.2124  Similarly, multifaceted educational bundles, such as the one described by Murch et al,23  can significantly improve adherence to guidelines. Two previous studies conducted by our research team in 2017 and 2018 revealed that the implementation of a QI intervention was successful in reducing the use of pharmacotherapy in AB in PC centers and the ED.7,13  Briefly, the first QI initiative was implemented in 20 PC centers, decreasing rates of albuterol and steroid use from 56% to 38% and from 24% to 13%, respectively, in the 2016–2017 AB season.7  After a new QI initiative that incorporated the referral ED, the PC centers’ prescribing rates of albuterol, steroids, and antibiotics fell from 38% to 16%, from 12.9% to 3.6%, and from 26.9% to 9.5%, respectively, and the percentage of infants receiving salbutamol in the ED fell from 13.8% to 9.1% in the following AB season.13  A conclusion of that research was that the combination of showing clinicians their performance data, compared with that of their peers, and collaboration between the ED and PC centers had the greatest impact on the results of the improvement initiative. Nonetheless, we found that 15% of infants with AB in PC and 10% in the ED continued to be treated with bronchodilators, and there was still wide variation in prescribing, especially among PC providers. These data revealed that there was still room for improvement and also raised concerns about the sustainability of the improvement obtained.

Clinical pathways have emerged as a potentially useful knowledge translation strategy for promoting effective health care. As clinical decision-making tools, clinical pathways operationalize best evidence-based recommendations into an accessible bedside format for health provider teams.2529  Nonetheless, the implementation strategy needs to be developed to ensure not only changes in clinician behavior but also the support required from patients and parents. Carande et al30  investigated potential changes in the management of AB by general practitioners in the UK after publication of the 2015 National Institute for Health and Care Excellence guideline. They found that 23% of general practitioners had changed their practice, but only 7% did so as a direct result of the guideline. This pattern points to the complexity of improving clinical practice and highlights the need for more effective improvement strategies. There is little information regarding the successful implementation of integrated care pathways in the pediatric field, and, in relation to this, our study provides evidence of their usefulness for the improvement of clinical practice. Our next step will be to roll out the BICP to all districts of the Basque Health Service, which will allow us to verify its applicability and explore conditions under which providers become more or less engaged in using the pathway.31 

Continuous QI requires a significant investment in time and effort, and this may be lacking when there is staff or organizational turnover.32  For this reason, we believe that involving families and providers in quality teams for the design of a clinical pathway for AB is a promising approach to making improvements more successful. To our knowledge, the current study is the first that incorporates the experience of families in a BICP using a design thinking approach. It is plausible that a gradual change in the perception of families that medications have no place in the treatment of AB is more likely than any guideline to facilitate clinicians’ decisions to not prescribe. In this way, it seems key to provide information, education, and local resources to families, taking into account their experience with AB. It also seems important to know the expectations of families and identify the factors that are the most important to them in the management of their child throughout the disease process. This information may improve not only the quality of care but also the satisfaction of families and their trust in the health system, making it easier for staff to make the most appropriate clinical decisions. The large number of visits and interactions in our social networks are indicative of the role that family awareness has played in the success of our improvement initiative.

Our study has several limitations. First, it only included 2 PC health districts, and, even when QI methods are properly applied, the success of a project still depends on contextual factors. Context affects resources, leadership support, data infrastructure, team motivation, and team performance, among other factors. For these reasons, the same project may thrive in a supportive context and fail elsewhere. Second, we did not include a control group, and it is therefore possible that our findings are the result of secular trends rather than being directly related to our interventions. Nonetheless, data collected in the same periods from nearby health districts where there were no related interventions revealed no change in their high salbutamol prescribing rates. Lastly, we did not review patient health records to assess whether clinicians used the McConnochie criteria for the diagnosis of AB,16  as recommended by the established protocol, and hence differences between clinicians in the diagnostic criteria applied could have led to differences in individual prescribing rates. Overall, however, we believe these limitations are unlikely to significantly alter the conclusions of the study.

We have shown that a bronchiolitis clinical pathway that incorporates the experiences of families and professionals has resulted in long-lasting, substantial decreases in the use of medications in clinical practice. We believe that the characteristics of this intervention may make the improvement sustainable in future AB seasons. Finally, studies in which researchers use implementation methodology are needed to determine which components of our interventions were most effective in changing provider behavior.

We thank Dr Marta Perez-Saracho, Mr Ines Gallego, and Ms Raquel Benito for their contribution to the design of the study and review of the article.

Drs Montejo and Benito conceptualized and designed the study, supervised data collection, analyzed the data, and wrote and critically revised the initial draft of the manuscript; Dr Paniagua collaborated in the study design and wrote and critically revised the initial draft of the manuscript; Dr Saiz-Hernando collaborated in the design of the study, participated in data collection, and critically revised the manuscript; Mrs Martínez-Indart collaborated in the design of the study, analyzed the data, revised multiple versions of the initial manuscript, and critically revised the final manuscript; Dr Pijoan analyzed the data and decisively contributed to the latest version of the manuscript; Mrs Castelo and Mrs Martín collaborated in the design of the study, participated in data collection, revised multiple versions of the initial manuscript, and critically revised the final manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: Funded by an annual research grant from the Spanish Society of Pediatric Emergency Medicine in 2018. No other external funding was secured for this study.

AB

acute bronchiolitis

BICP

bronchiolitis integrated care pathway

CI

confidence interval

ED

emergency department

IQR

interquartile range

PC

primary care

QI

quality improvement

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.