Original Article
Impact of a new acute bronchiolitis protocol on clinical practice
Impacto en la práctica clínica de un nuevo protocolo de bronquiolitis aguda
Read
6487
Timeswas read the article
2231
Total PDF
4256
Total HTML
Share statistics
array:25 [ "pii" => "S2341287918302229" "issn" => "23412879" "doi" => "10.1016/j.anpede.2018.02.012" "estado" => "S300" "fechaPublicacion" => "2019-02-01" "aid" => "2409" "copyright" => "Asociación Española de Pediatría" "copyrightAnyo" => "2017" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "An Pediatr (Barc). 2019;90:79-85" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 1292 "formatos" => array:3 [ "EPUB" => 96 "HTML" => 890 "PDF" => 306 ] ] "Traduccion" => array:1 [ "es" => array:20 [ "pii" => "S169540331830122X" "issn" => "16954033" "doi" => "10.1016/j.anpedi.2018.02.017" "estado" => "S300" "fechaPublicacion" => "2019-02-01" "aid" => "2409" "copyright" => "Asociación Española de Pediatría" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "An Pediatr (Barc). 2019;90:79-85" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 10205 "formatos" => array:3 [ "EPUB" => 155 "HTML" => 6941 "PDF" => 3109 ] ] "es" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original</span>" "titulo" => "Impacto en la práctica clínica de un nuevo protocolo de bronquiolitis aguda" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "79" "paginaFinal" => "85" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Impact of a new acute bronchiolitis protocol on clinical practice" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Raquel Jiménez García, David Andina Martínez, Belén Palomo Guerra, Silvia Escalada Pellitero, Mercedes de la Torre Espí" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Raquel" "apellidos" => "Jiménez García" ] 1 => array:2 [ "nombre" => "David" "apellidos" => "Andina Martínez" ] 2 => array:2 [ "nombre" => "Belén" "apellidos" => "Palomo Guerra" ] 3 => array:2 [ "nombre" => "Silvia" "apellidos" => "Escalada Pellitero" ] 4 => array:2 [ "nombre" => "Mercedes" "apellidos" => "de la Torre Espí" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2341287918302229" "doi" => "10.1016/j.anpede.2018.02.012" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341287918302229?idApp=UINPBA00005H" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S169540331830122X?idApp=UINPBA00005H" "url" => "/16954033/0000009000000002/v1_201902020612/S169540331830122X/v1_201902020612/es/main.assets" ] ] "itemSiguiente" => array:20 [ "pii" => "S2341287918302205" "issn" => "23412879" "doi" => "10.1016/j.anpede.2018.06.007" "estado" => "S300" "fechaPublicacion" => "2019-02-01" "aid" => "2482" "copyright" => "Asociación Española de Pediatría" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "An Pediatr (Barc). 2019;90:86-93" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 1056 "formatos" => array:3 [ "EPUB" => 122 "HTML" => 651 "PDF" => 283 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>" "titulo" => "Child hospital admissions associated with influenza virus infection in 6 Spanish cities (2014–2016)" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "86" "paginaFinal" => "93" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hospitalizaciones infantiles asociadas a infección por virus de la gripe en 6 ciudades de España (2014–2016)" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1562 "Ancho" => 2222 "Tamanyo" => 84975 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Distribution by month (number of cases) of hospital admissions due to community-acquired influenza infection (2014–2015 and 2015–2016 flu seasons).</p>" ] ] ] "autores" => array:2 [ 0 => array:2 [ "autoresLista" => "Javier Arístegui Fernández, Eduardo González Pérez-Yarza, María José Mellado Peña, Carlos Rodrigo Gonzalo de Liria, Teresa Hernández Sampelayo, Juan José García García, Jesús Ruiz Contreras, David Moreno Pérez, Elisa Garrote Llanos, José Tomás Ramos Amador, Carlos Gustavo Cilla Eguiluz, María Méndez Hernández" "autores" => array:13 [ 0 => array:2 [ "nombre" => "Javier" "apellidos" => "Arístegui Fernández" ] 1 => array:2 [ "nombre" => "Eduardo" "apellidos" => "González Pérez-Yarza" ] 2 => array:2 [ "nombre" => "María José" "apellidos" => "Mellado Peña" ] 3 => array:2 [ "nombre" => "Carlos" "apellidos" => "Rodrigo Gonzalo de Liria" ] 4 => array:2 [ "nombre" => "Teresa" "apellidos" => "Hernández Sampelayo" ] 5 => array:2 [ "nombre" => "Juan José" "apellidos" => "García García" ] 6 => array:2 [ "nombre" => "Jesús" "apellidos" => "Ruiz Contreras" ] 7 => array:2 [ "nombre" => "David" "apellidos" => "Moreno Pérez" ] 8 => array:2 [ "nombre" => "Elisa" "apellidos" => "Garrote Llanos" ] 9 => array:2 [ "nombre" => "José Tomás" "apellidos" => "Ramos Amador" ] 10 => array:2 [ "nombre" => "Carlos Gustavo" "apellidos" => "Cilla Eguiluz" ] 11 => array:2 [ "nombre" => "María" "apellidos" => "Méndez Hernández" ] 12 => array:1 [ "colaborador" => "en representación del grupo de estudio HOSPIGRIP" ] ] ] 1 => array:2 [ "autoresLista" => "" "autores" => array:1 [ 0 => array:1 [ "colaborador" => "Authors of the HOSPIGRIP research group" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S169540331830300X" "doi" => "10.1016/j.anpedi.2018.06.012" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S169540331830300X?idApp=UINPBA00005H" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341287918302205?idApp=UINPBA00005H" "url" => "/23412879/0000009000000002/v1_201902020626/S2341287918302205/v1_201902020626/en/main.assets" ] "itemAnterior" => array:20 [ "pii" => "S2341287918302266" "issn" => "23412879" "doi" => "10.1016/j.anpede.2018.06.008" "estado" => "S300" "fechaPublicacion" => "2019-02-01" "aid" => "2488" "copyright" => "Asociación Española de Pediatría" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "An Pediatr (Barc). 2019;90:72-8" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2443 "formatos" => array:3 [ "EPUB" => 102 "HTML" => 1340 "PDF" => 1001 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>" "titulo" => "Treatment with high-flow oxygen therapy in asthma exacerbations in a paediatric hospital ward: Experience from 2012 to 2016" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "72" "paginaFinal" => "78" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tratamiento con oxigenoterapia de alto flujo en las crisis asmáticas en la planta de hospitalización de pediatría: nuestra experiencia" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 686 "Ancho" => 2949 "Tamanyo" => 80228 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Values of RR, HR and pulmonary score in patients treated with high-flow oxygen therapy at admission, before initiation of HFNC and at 3<span class="elsevierStyleHsp" style=""></span>h of treatment.</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">HFNC, high-flow nasal cannula therapy; HR, heart rate, RR, respiratory rate.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Felipe González Martínez, María Isabel González Sánchez, Blanca Toledo del Castillo, Jimena Pérez Moreno, María Medina Muñoz, Cristina Rodríguez Jiménez, Rosa Rodríguez Fernández" "autores" => array:7 [ 0 => array:2 [ "nombre" => "Felipe" "apellidos" => "González Martínez" ] 1 => array:2 [ "nombre" => "María Isabel" "apellidos" => "González Sánchez" ] 2 => array:2 [ "nombre" => "Blanca" "apellidos" => "Toledo del Castillo" ] 3 => array:2 [ "nombre" => "Jimena" "apellidos" => "Pérez Moreno" ] 4 => array:2 [ "nombre" => "María" "apellidos" => "Medina Muñoz" ] 5 => array:2 [ "nombre" => "Cristina" "apellidos" => "Rodríguez Jiménez" ] 6 => array:2 [ "nombre" => "Rosa" "apellidos" => "Rodríguez Fernández" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S1695403318303060" "doi" => "10.1016/j.anpedi.2018.06.015" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1695403318303060?idApp=UINPBA00005H" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341287918302266?idApp=UINPBA00005H" "url" => "/23412879/0000009000000002/v1_201902020626/S2341287918302266/v1_201902020626/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>" "titulo" => "Impact of a new acute bronchiolitis protocol on clinical practice" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "79" "paginaFinal" => "85" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Raquel Jiménez García, David Andina Martínez, Belén Palomo Guerra, Silvia Escalada Pellitero, Mercedes de la Torre Espí" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Raquel" "apellidos" => "Jiménez García" "email" => array:1 [ 0 => "raquel.jimgar@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "David" "apellidos" => "Andina Martínez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Belén" "apellidos" => "Palomo Guerra" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Silvia" "apellidos" => "Escalada Pellitero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 4 => array:3 [ "nombre" => "Mercedes" "apellidos" => "de la Torre Espí" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Urgencias, Hospital Infantil Universitario Niño Jesús, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Pediatría, Facultad de Medicina, Universidad Autónoma de Madrid, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Pediatría, Hospital Infantil Universitario Niño Jesús, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Impacto en la práctica clínica de un nuevo protocolo de bronquiolitis aguda" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Acute bronchiolitis (AB) is defined as the first acute episode of respiratory distress with wheezing and crackles, preceded by a clinical picture of viral infection of the upper respiratory airway. It affects children aged less than 24 months and generally exhibits a seasonal pattern. In Spain, the epidemic season ranges from November to March.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a> In up to 83% of cases, the causative agent is respiratory syncytial virus (RSV), although coinfection by other viruses is common.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Most cases of AB are mild and can be treated at the outpatient level. However, between 2% and 3% of children require hospital admission,<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">3</span></a> and AB is the leading cause of hospital admission in infants aged less than 12 months.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The diagnostic tests and treatment recommended in clinical practice have changed in recent years based on the emerging scientific evidence.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Acute bronchiolitis is a clinical diagnosis, and there is no evidence supporting the routine performance of diagnostic tests (complete blood count, acute phase reactants, chest X-ray).<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">5,6</span></a> The detection of respiratory viruses in nasopharyngeal samples does not guide the management or predict the outcome of patients with AB.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">7</span></a> Viral detection tests may be indicated during the bronchiolitis season in patients with risk factors presenting with cold-like symptoms to assess the need of inpatient monitoring and in patients with a diagnosis of AB that require hospital admission for the purpose of implementing the necessary isolation measures.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Treatment options beyond guaranteeing adequate hydration and oxygen saturation are quite limited.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The most recent clinical practice guidelines do not recommend many of the treatments that have been used in everyday clinical practice (such as nebulised salbutamol or adrenaline).<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">5,8,9</span></a> A systematic Cochrane review<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">10</span></a> demonstrated that neither oxygen saturation, the time elapsed to resolution of symptoms or the length of stay improved with administration of nebulised salbutamol. Nebulised adrenaline does not seem to benefit these patients either.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">11</span></a> There is no consensus regarding the use of nebulised hypertonic saline solution (HSS), although its use is generally reserved for hospitalised patients.<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">12,13</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Antibiotherapy is not indicated either, as the incidence of bacterial superinfection in children with AB is very low, with a risk of bacteraemia or meningitis of less than 1%.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">14</span></a> Furthermore, their use can cause adverse events and promote the development of microbial drug resistance.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The prevalence of BA and the variability in its management<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">15</span></a> make this disease a perfect candidate for monitoring adequate use of resources in clinical practice in the paediatric emergency department (ED) setting.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The aim of the study was to determine the impact of the updating and dissemination of a new protocol for the treatment of AB on the use of resources that are not indicated in the ED.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0050" class="elsevierStylePara elsevierViewall">We performed a retrospective and comparative study of patients that received a diagnosis of AB in the ED selected by simple randomisation during 2 bronchiolitis seasons: before the implementation of the new protocol (December 2014) and after its implementation (December 2016). We obtained the data for the study by reviewing patient health records. Based on the evidence available in the literature, at the time we designed the study about 60% of patients with bronchiolitis in the ED received bronchodilators,<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">15</span></a> and similar interventions have succeeded in reducing the use of bronchodilators by 12%<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">16</span></a> and 17%.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">17</span></a> To calculate the sample size, we used this 60% value as the estimated proportion, and set the objective of reducing bronchodilator use by 15%, assuming an alpha error of 5% and a beta error of 10%. The estimated sample size was <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>114, and we decided to select 130 patients per season to minimise the impact of potential losses.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The AB protocol was debated by the chiefs of each of the departments involved in its implementation in 2015, and was finally updated after obtaining the approval of the health care quality committee of the hospital on November 1, 2016. It was then distributed to all permanent and resident physicians in the hospital in a clinical meeting held at the beginning of the RSV epidemic season and via electronic mail, accompanied by a document with the supporting evidence. The protocol was also available to all clinicians in the hospital intranet. The updated protocol placed particular emphasis on restricting the use of bronchodilators in the ED to cases of severe bronchiolitis that did not improve with supplemental oxygen and on identifying the patients in whom diagnostic tests were actually indicated (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Definition</span><p id="par0060" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Acute bronchiolitis:</span> first acute episode of respiratory distress with wheezing preceded by a cold-like clinical picture of the upper respiratory airway which affects children younger than 24 months of age.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0070" class="elsevierStylePara elsevierViewall">We categorised the <span class="elsevierStyleItalic">severity of AB</span> using the modified Wood-Downes-Ferré (mWDF) scale.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">18</span></a></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Risk factors for poor outcome of AB</span>: age<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>4 weeks, preterm birth before 34 weeks’ gestation, cystic fibrosis, bronchopulmonary dysplasia, heart disease, immunodeficiency, neurologic disease, severe malnutrition.</p></li></ul></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Inclusion criteria</span><p id="par0080" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0085" class="elsevierStylePara elsevierViewall">Children aged less than 24 months with a ED discharge diagnosis of AB.</p></li></ul></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Exclusion criteria</span><p id="par0090" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0095" class="elsevierStylePara elsevierViewall">Patients in which a meticulous review of the health records revealed previous episodes of bronchiolitis, bronchitis or bronchospasm.</p></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Data collection</span><p id="par0100" class="elsevierStylePara elsevierViewall">We selected clinical variables taking into consideration the quality indicators featured in the literature and for which there are specific recommendations in the protocol of our hospital.</p><p id="par0105" class="elsevierStylePara elsevierViewall">We collected data for the following variables:<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0110" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Demographic</span>: date of service, age, sex, risk factors for poor outcome of AB.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0115" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Clinical</span>: fever, vomiting, food refusal, apnoea, cyanosis, lung auscultation findings, severity of AB (mWDF).</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">-</span><p id="par0120" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Diagnostic tests</span>: rapid RSV detection test, chest X-rays, blood tests.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">-</span><p id="par0125" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Treatment</span>: nebulised salbutamol, nebulised adrenaline, nebulised HSS, corticosteroids, antibiotherapy and supplemental oxygen in the ED; salbutamol inhaled salbutamol and corticosteroids after discharge.</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">-</span><p id="par0130" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Outcome</span>: fate (home, inpatient ward, PICU), readmission in the following 72<span class="elsevierStyleHsp" style=""></span>h, length of stay in ED.</p></li></ul></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Statistical analysis</span><p id="par0135" class="elsevierStylePara elsevierViewall">We have described quantitative variables using measures of central tendency and dispersion (mean with standard deviation and median with interquartile range) and qualitative variables as absolute frequencies (<span class="elsevierStyleItalic">n</span>) and relative frequencies (%). In the analysis of the differences between the 2 groups under study (pre- and post-introduction of the protocol), we compared quantitative variables by means of the Student's <span class="elsevierStyleItalic">t</span> test if they followed a normal distribution, and otherwise by means of the Mann–Whitney <span class="elsevierStyleItalic">U</span> test. We compared qualitative variables using the chi square test or the Fisher exact test. We defined statistical significance as a <span class="elsevierStyleItalic">P</span>-value of less than 0.05 in any of the tests. The statistical analysis was performed with the software SPSS version 20.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Ethical considerations</span><p id="par0140" class="elsevierStylePara elsevierViewall">The study adhered to the principles of the Convenio de Oviedo and of the Declaration of Helsinki and was approved by the clinical research ethics committee of the hospital.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results</span><p id="par0145" class="elsevierStylePara elsevierViewall">A total of 365 patients received a diagnosis of AB in December of 2014 (pre-protocol group), and a total of 392 received it in December 2016 (post-protocol group). We selected 130 patients from each group by simple randomisation. We excluded 19 patients that did not meet the criteria for AB. The final sample included 113 children in the pre-protocol group and 128 in the post-protocol group.</p><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Demographic and clinical characteristics</span><p id="par0150" class="elsevierStylePara elsevierViewall">The demographic characteristics were similar in both groups, with the exception of the mean age of the patients, which was slightly greater in 2016 (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). The percentage of children aged less than 6 months was similar in both groups (56.6% vs 48.4%, <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.2). The clinical manifestations were also similar, although the frequency of crackles on auscultation was greater in the post-protocol group (38.1% vs 58.6%, <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Diagnostic tests</span><p id="par0155" class="elsevierStylePara elsevierViewall">We did not find statistically significant differences in the performance of blood tests or chest X-rays. There was a significant decrease in the orders for rapid RSV detection tests in nasopharyngeal aspirate samples (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.01) (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Treatment</span><p id="par0160" class="elsevierStylePara elsevierViewall">Overall, the prescription of medications decreased significantly (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>).</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0165" class="elsevierStylePara elsevierViewall">There was a decrease in the use of nebulised salbutamol both in the ED (33.6% pre-protocol vs 19.5% post-protocol; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.01) and in its prescription at discharge for home-based treatment (46.7% pre-protocol vs 15.2% post-protocol; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001). There were also significant reductions in the use of nebulised adrenaline (12.4% vs 2.4% <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.002) and nebulised HSS (5.3% vs 0.8%; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.04) in the ED.</p><p id="par0170" class="elsevierStylePara elsevierViewall">The prescription of antibiotics was similar in both periods (pre-protocol, 10.6%; post-protocol, 7%).</p><p id="par0175" class="elsevierStylePara elsevierViewall">A greater proportion of patients received supplemental oxygen in 2016 (14.2% vs 19.5%), although this difference was not statistically significant (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.17).</p><p id="par0180" class="elsevierStylePara elsevierViewall">The use of oral corticosteroids was very rare in both groups, both in the ED (2.7% in 2014 and 3.9% in 2016) and in post-discharge treatment (3.7% in 2014 and 0%, in 2016).</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Outcome</span><p id="par0185" class="elsevierStylePara elsevierViewall">The fate of patients after discharge from ED (admission to ward, admission to PICU, home), the number of patients that returned to the ED within 72<span class="elsevierStyleHsp" style=""></span>h from discharge and the median length of stay in the ED were similar in both groups (<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>).</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Discussion</span><p id="par0190" class="elsevierStylePara elsevierViewall">The intervention at the ED level of introducing and disseminating an updated protocol for AB proved effective, as it achieved decreases in the use of bronchodilators (salbutamol and adrenaline) and nebulised HSS for treatment of AB, without associated increases in length of stay in the ED, admissions to the ward or PICU or readmission within 72<span class="elsevierStyleHsp" style=""></span>h from discharge. We found the greatest decrease in the percentage of patients that received a prescription for post-discharge treatment with salbutamol, which was of 30%. The demographic and clinical characteristics of the patients and the severity of AB determined by means of the mWDF scale were very similar in the 2 patient cohorts, with the exception of age. Although the median patient age was higher in 2016 (5.8 months in 2014 vs 6.7 in 2016), this did not seem to have an effect on decision-making regarding treatment or on patient fate (admission or discharge home). The positive impact of the protocol was consistent with the findings of other studies, although these interventions are not always as effective.<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">19,20</span></a> It is possible that reinforcing the introduction of the protocol by holding informational meetings contributed to this outcome.</p><p id="par0195" class="elsevierStylePara elsevierViewall">The impact on the ordering of diagnostic tests was not significant except for the rapid RSV detection test, which was probably due to the fact that the proportion of patients evaluated by means of blood tests (2.7% pre-protocol vs 3.3% post-protocol) and X-rays was already very low before the introduction of the new protocol.</p><p id="par0200" class="elsevierStylePara elsevierViewall">The percentage of patients that underwent a chest X-ray examination (2014, 8.8%; 2016, 5.5%) was very low compared to similar studies performed in hospital settings, which have reported proportions of 51% to 95% in patients admitted with AB.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">19</span></a> Johnson demonstrated that the use of X-rays was less frequent in children's hospitals, such as ours, compared to general hospitals, and that chest X-rays were ordered more frequently in patients admitted to hospital compared to patients discharged home from the ED.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">20</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">The group that developed the new protocol decided to continue testing for RSV in children in whom admission was indicated to facilitate the prompt implementation of measures to prevent transmission, separating RSV-positive patients from RSV-negative patients. However, given that the mechanisms of transmission of the different viruses that cause AB are similar (aerosol transmission through close contact with infected individuals, direct contact with fomites), some studies have suggested that infection control and prevention of nosocomial infection do not require identification of the causative virus, but rather the strict implementation of hygiene measures.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">21</span></a> The proportion of patients that underwent rapid testing for detection of RSV was very similar to the proportion of patients admitted to hospital, which reflected adherence to the protocol.</p><p id="par0210" class="elsevierStylePara elsevierViewall">Although inflammation plays an essential role in the pathophysiology of AB, no study to date has found evidence of the effectiveness of corticosteroids for treatment of a first episode of AB in previously healthy infants. For this reason, none of the current guidelines recommends their use.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">5,8,9</span></a> As occurred in other studies,<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">16,20</span></a> the protocol did not achieve a reduction in the prescription of corticosteroids due to the already low baseline proportion.</p><p id="par0215" class="elsevierStylePara elsevierViewall">In our series, antibiotic prescription (in 10.6% of patients pre-protocol and 7% post-protocol) was less frequent compared to similar past studies,<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">22</span></a> where the proportion has ranged between 27% and 45%, although it is important to take into account that those studies were conducted in hospitalised patients.</p><p id="par0220" class="elsevierStylePara elsevierViewall">Oxygen therapy is one of the few interventions recommended in the management of AB.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">5,8,9</span></a> The debate regarding oxygen therapy revolves around the saturation threshold after which it should be given. Consistent with similar studies in the literature,<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">20</span></a> our study did not find any differences in the proportion of children that received supplemental oxygen in each season.</p><p id="par0225" class="elsevierStylePara elsevierViewall">In our study, the proportion of patients discharged home (approximately 70%) was similar in both groups, but a little higher compared to the proportion reported in the literature (57%).<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">23</span></a> A possible explanation for this is that in some cases, especially those of bronchiolitis of moderate severity, our ED discharges the patient and recommends scheduling an appointment for clinical followup in the next 24<span class="elsevierStyleHsp" style=""></span>h, which decreases the rate of admissions at the expense of the rate of readmission. In addition, in Spain December is the month with the most holidays, which at times impedes proper outpatient followup of patients with mild disease at the primary care level.</p><p id="par0230" class="elsevierStylePara elsevierViewall">In health care, quality is not only a parameter necessary for adequate management of resources, but it is also an ethical imperative. Evaluating care delivery is important to implement improvement plans, prioritising critical diseases such as AB-RSV infection, which year after year give rise to an outbreak that overwhelms paediatric EDs and primary care paediatrics clinics.</p><p id="par0235" class="elsevierStylePara elsevierViewall">Our results demonstrate that the introduction and dissemination of an evidence-based protocol can improve health care quality, as it achieved a reduction in the number of diagnostic and therapeutic interventions that are not recommended in patients with AB without a negative impact on patient outcomes. Thus, to consolidate these results, we have decided to go on with the intervention by providing all the staff that may be on call in the ED feedback regarding these outcomes, and holding an informational session every year right before the beginning of the AB-RSV epidemic season to remind the staff of the most relevant points of the protocol for the management of AB-RSV infection.</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conflicts of interest</span><p id="par0240" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1145082" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1075353" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1145083" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1075352" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Materials and methods" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Definition" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Inclusion criteria" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Exclusion criteria" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Data collection" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Statistical analysis" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Ethical considerations" ] ] ] 6 => array:3 [ "identificador" => "sec0045" "titulo" => "Results" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0050" "titulo" => "Demographic and clinical characteristics" ] 1 => array:2 [ "identificador" => "sec0055" "titulo" => "Diagnostic tests" ] 2 => array:2 [ "identificador" => "sec0060" "titulo" => "Treatment" ] 3 => array:2 [ "identificador" => "sec0065" "titulo" => "Outcome" ] ] ] 7 => array:2 [ "identificador" => "sec0070" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0075" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-12-05" "fechaAceptado" => "2018-02-27" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1075353" "palabras" => array:5 [ 0 => "Acute bronchiolitis" 1 => "Evidence-based guidelines" 2 => "Clinical practice variation" 3 => "Treatment" 4 => "Diagnostic tests" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1075352" "palabras" => array:5 [ 0 => "Bronquiolitis aguda" 1 => "Guía basada en la evidencia" 2 => "Variación en la práctica clínica" 3 => "Tratamiento" 4 => "Test diagnósticos" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The prevalence and the variability of clinical practice in acute bronchiolitis make it a perfect candidate to monitor the proper use of resources. The aim of this study is to analyse the differences in the use of non-recommended resources in the management of bronchiolitis in the Emergency Department, before and after the establishment of a new protocol.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective study was conducted on a sample of patients diagnosed with acute bronchiolitis in the Emergency Department of a tertiary hospital, before (December 2014) and after (December 2016) the implementation of a new protocol. A comparison was made on the use of diagnostic tests and treatments in both groups.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The analysis included a total of 113 patients with acute bronchiolitis examined in December 2014, and 128 patients in December 2016. The clinical characteristics in both groups were similar. In the post-protocol period, there was a significant decrease in the use of salbutamol, both in the Emergency Department (33.6% vs 19.5%, <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.01) and at discharge (46.7% vs 15.2%, <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001); adrenaline (12.4% vs 2.4%, <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.002); and nebulised hypertonic saline solution (5.3% vs 0.8%, <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.04). Rapid respiratory syncytial virus (RSV) testing was also decreased (40.7% vs 26.6%, <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.01). This decrease was not associated with an increase in the number of admissions or re-assessments in the Emergency Department.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The establishment of a new protocol for acute bronchiolitis decreased the use of non-recommended resources, mainly the use of bronchodilators and rapid RSV testing.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La prevalencia y la variabilidad de la práctica clínica en la bronquiolitis aguda la convierten en una candidata perfecta para evaluar la adecuación en el uso de recursos asistenciales. El objetivo de este estudio es comparar la utilización de recursos no recomendados para la atención de pacientes con bronquiolitis en el Servicio de Urgencias, antes y después de la instauración de un nuevo protocolo basado en las recomendaciones actuales.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo de una muestra de pacientes diagnosticados de bronquiolitis aguda en el Servicio de Urgencias de un hospital terciario y seleccionados mediante aleatorización simple antes (diciembre de 2014) y después (diciembre de 2016) de la instauración de un nuevo protocolo. Se comparó el uso de pruebas diagnósticas y el tratamiento en ambos grupos.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se han comparado 113 pacientes con bronquiolitis aguda atendidos en diciembre de 2014 y 128 en diciembre de 2016. Las características clínicas en ambos grupos eran similares. En el período posprotocolo se observó una disminución significativa en la utilización de salbutamol, tanto en el servicio de urgencias (33,6% vs 19,5%, p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,01) como al alta (46,7% vs 15,2%, p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,001); de adrenalina (12,4% vs 2,4%, p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,002) y de suero salino hipertónico nebulizado (5,3% vs 0,8%, p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,04). También disminuyó la solicitud de la prueba de detección rápida de VRS (40,7% vs 26,6%, p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,01). No se produjo un aumento en el número de ingresos o readmisiones en urgencias en las siguientes 72<span class="elsevierStyleHsp" style=""></span>horas.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La instauración de un nuevo protocolo de bronquiolitis aguda disminuyó la utilización de recursos no recomendados, principalmente el uso de broncodilatadores y de la prueba de detección rápida del VRS.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Jiménez García R, Andina Martínez D, Palomo Guerra B, Escalada Pellitero S, de la Torre Espí M. Impacto en la práctica clínica de un nuevo protocolo de bronquiolitis aguda. An Pediatr (Barc). 2019;90:79–85.</p>" ] ] "multimedia" => array:5 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">AB, acute bronchiolitis; RR, respiratory rate; RSV, respiratory syncytial virus.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Acute bronchiolitis is a clinical diagnosis. Testing for detection of RSV should only be performed in patients with risk factors or in case of hospital admission. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Assess severity in all children with AB. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Measure the RR and oxygen saturation in all children with AB. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chest X-rays are only indicated if severe complications are suspected, in patients without favourable outcomes or in case of diagnostic uncertainty. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Empiric treatment with nebulised salbutamol is only indicated in children aged more than 6 months with severe AB that does not improve with oxygen therapy. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Empiric treatment with nebulised adrenaline is only indicated in children aged less than 6 months with severe AB that does not improve with oxygen therapy. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Document the effectiveness of the empiric treatment (severity score or clinical judgement of paediatrician) and discontinue treatment if it has not been effective \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Corticosteroids are not indicated in these patients. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Antibiotherapy is not indicated in the absence of evidence of bacterial infection. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Oxygen: indicated to decrease the work of breathing in moderate-to-severe AB or when the oxygen saturation is less than 92% for a sustained period. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1954034.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Recommendations of the emergency department protocol for the management of acute bronchiolitis (2016).</p>" ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">IQR, interquartile range.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2014<br>Pre-protocol \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2016<br>Post-protocol \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Median age in months (IQR)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.8 (3.4–9.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.7 (3.6–11.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.08 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Male (%)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">64 (56.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">68 (53.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.33 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Risk factors (%)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (6.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (7.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.50 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Severity</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mild (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">59 (57.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">74 (60.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.41 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Moderate-severe (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">43 (42.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">49 (39.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1954035.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Sample characteristics.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">RSV, respiratory syncytial virus.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2014<br>Pre-protocol \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2016<br>Post-protocol \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Blood tests (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (2.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (2.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.59 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chest X-ray (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (8.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (5.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.22 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rapid RSV detection test in nasal aspirate sample (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46 (40.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">34 (26.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.01 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1954032.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Diagnostic tests performed in patients with acute bronchiolitis.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">ED, emergency department; HSS, hypertonic saline solution.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2014<br>Pre-protocol \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2016<br>Post-protocol \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Salbutamol in ED (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38 (33.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25 (19.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.010 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Salbutamol at home (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50 (46.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 (15.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Adrenalin in ED (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 (12.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (2.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.002 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">HSS in ED (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (5.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (0.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.042 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Antibiotics in ED (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (10.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.224 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Corticosteroids in ED (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (2.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (3.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.432 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Corticosteroids at home (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (3.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.055 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Oxygen therapy in ED (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 (14.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25 (19.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.175 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1954031.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Treatment of patients with acute bronchiolitis.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at5" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">ED, emergency department; IQR, interquartile range; PICU, paediatric intensive care unit.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2014<br>Pre-protocol \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2016<br>Post-protocol \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Admission to ward (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32 (28.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31 (24.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.282 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Return to ED after <72<span class="elsevierStyleHsp" style=""></span>h (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38 (33.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40 (32.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.588 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Admission to PICU (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (2.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (5.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.276 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Median length of stay in ED in hours (IQR) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.8 (0.4–1.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (0.5–2.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.167 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1954033.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Fate of patients with acute bronchiolitis.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:23 [ 0 => array:3 [ "identificador" => "bib0120" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Estudio de variabilidad en el abordaje de la bronquiolitis aguda en España en relación con la edad de los pacientes" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "Ochoa Sangrador C y Grupo Investigador del Proyecto aBREVIADo (BRonquiolitis-Estudio de Variabilidad, Idoneidad y Adecuación)" "etal" => false "autores" => array:1 [ 0 => "J. González de Dios" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "An Pediatr (Barc)" "fecha" => "2010" "volumen" => "72" "paginaInicial" => "4" "paginaFinal" => "18" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0125" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Viral etiologies of infant bronchiolitis, croup and upper respiratory illness during 4 consecutive years" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E.K. Miller" 1 => "T. Gebretsadik" 2 => "K.N. Carroll" 3 => "W.D. Dupont" 4 => "Y.A. Mohamed" 5 => "L.L. Morin" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Pediatr Infect Dis J" "fecha" => "2013" "volumen" => "32" "paginaInicial" => "950" "paginaFinal" => "955" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0130" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Viral bronchiolitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "T.A. Florin" 1 => "A.C. Plint" 2 => "J.J. Zorc" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Lancet" "fecha" => "2017" "volumen" => "389" "paginaInicial" => "211" "paginaFinal" => "224" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0135" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Pfuntner A, Wier L, Stocks C. Most frequent conditions in US Hospitals, 2010. HCUP Statistical Brief #148, 2013. Available from: <a id="intr0010" class="elsevierStyleInterRef" href="http://www.hcup-us.ahrq.gov/reports/statbriefs/sb148.pdf">http://www.hcup-us.ahrq.gov/reports/statbriefs/sb148.pdf</a> [accessed October 2017]." ] ] ] 4 => array:3 [ "identificador" => "bib0140" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Bronchiolitis: Diagnosis and management of bronchiolitis in children" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "National Collaborating Centre for Women's and Children's Health (UK)" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "2015" "editorial" => "National Institute for Health and Care Excellence (UK)" "editorialLocalizacion" => "London" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0145" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Impact of chest radiography for children with lower respiratory tract infection: a propensity score approach" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E. Ecochard-Dugelay" 1 => "M. Beliah" 2 => "C. Boisson" 3 => "F. Perreaux" 4 => "J. de Laveaucoupet" 5 => "P. Labrune" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "PLoS ONE" "fecha" => "2014" "volumen" => "9" "paginaInicial" => "e96189" ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0150" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Virologic testing in bronchiolitis: does it change management decisions and predict outcomes?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "F. Stollar" 1 => "G. Alcoba" 2 => "A. Gervaix" 3 => "C.B. Argiroffo" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Eur J Pediatr" "fecha" => "2014" "volumen" => "173" "paginaInicial" => "1429" "paginaFinal" => "1435" ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0155" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical practice guideline: the diagnosis, management, and prevention of bronquiolitis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S.L. Ralston" 1 => "A.S. Lieberthal" 2 => "H.C. Meissner" 3 => "B.K. Alverson" 4 => "J.E. Baley" 5 => "A.M. Gadomiski" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Pediatrics" "fecha" => "2014" "volumen" => "134" "paginaInicial" => "e1474" "paginaFinal" => "e1502" ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0160" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute bronchiolitis clinical practice guideline: recommendations for clinical practice" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M.S. Nebot" 1 => "G.C. Teruel" 2 => "C.L. Cubells" 3 => "M.D. Sabadell" 4 => "J.P. Fernández" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "An Pediatr (Barc)" "fecha" => "2010" "volumen" => "73" "paginaInicial" => "208" ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0165" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "Art. N.°: CD001266" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Bronchodilators for bronchiolitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A.M. Gadomski" 1 => "M.B. Scribani" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/14651858.CD001266.pub4" "Revista" => array:3 [ "tituloSerie" => "Cochrane Database Syst Rev" "fecha" => "2014" "volumen" => "6" ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0170" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "Art. N.°: CD003123" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Epinephrine for bronchiolitis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "L. Hartling" 1 => "L.M. Bialy" 2 => "B. Vandermeer" 3 => "L. Tjosvold" 4 => "D.W. Johnson" 5 => "A.C. Plint" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/14651858.CD003123.pub3" "Revista" => array:3 [ "tituloSerie" => "Cochrane Database Syst Rev" "fecha" => "2011" "volumen" => "6" ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0175" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Nebulized hypertonic saline for acute bronchiolitis: a systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "L. Zheng" 1 => "R.A. Mendoza-Sassi" 2 => "T.P. Klassen" 3 => "C. Wainwright" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Pediatrics" "fecha" => "2015" "volumen" => "136" "paginaInicial" => "687" "paginaFinal" => "701" ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0180" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Bronchiolitis: doing less and still getting better" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "D.N. Cornfield" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Pediatrics" "fecha" => "2014" "volumen" => "133" "paginaInicial" => "213" "paginaFinal" => "214" ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0185" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "Art. N.°: CD005189" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Antibiotics for bronchiolitis in children under two years of age" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "R. Farley" 1 => "G.K. Spurling" 2 => "L. Eriksson" 3 => "C.B. del Mar" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/14651858.CD005189.pub4" "Revista" => array:3 [ "tituloSerie" => "Cochrane Database Syst Rev" "fecha" => "2014" "volumen" => "10" ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0190" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Management of acute bronchiolitis in emergency wards in Spain: variability and appropriateness analysis (aBREVIADo Project)" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "Research Group of the aBREVIADo Project" "etal" => false "autores" => array:2 [ 0 => "C. Ochoa Sangrador" 1 => "J. González de Dios" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Eur J Pediatr" "fecha" => "2012" "volumen" => "171" "paginaInicial" => "1109" "paginaFinal" => "1119" ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0195" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Decreasing unnecessary utilization in acute bronchiolitis care: results from the value in inpatient pediatrics network" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. Ralston" 1 => "M. Garber" 2 => "S. Narang" 3 => "M. Shen" 4 => "B. Pate" 5 => "J. Pope" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Hosp Med" "fecha" => "2013" "volumen" => "8" "paginaInicial" => "25" "paginaFinal" => "30" ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0200" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sustaining the implementation of an evidence-based guideline for bronchiolitis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P.H. Perlstein" 1 => "U.R. Kotagal" 2 => "P.J. Schoettker" 3 => "H.D. Atherton" 4 => "M.K. Farrell" 5 => "W.E. Gerhardt" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Pediatr Adolesc Med" "fecha" => "2000" "volumen" => "154" "paginaInicial" => "1001" "paginaFinal" => "1007" "itemHostRev" => array:3 [ "pii" => "S1935861X16303941" "estado" => "S300" "issn" => "1935861X" ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0205" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Adrenalina subcutánea versus salbutamol inhalado en el tratamiento de la crisis asmática infantil" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "J. Ferrés" 1 => "M.A. Mangues" 2 => "R. Farre" 3 => "A. Juliá" 4 => "J. Bonal" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "An Esp Pediatr" "fecha" => "1987" "volumen" => "27" "paginaInicial" => "37" "paginaFinal" => "42" "itemHostRev" => array:3 [ "pii" => "S0272638617307540" "estado" => "S300" "issn" => "02726386" ] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0210" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Bronchiolitis management before and after the AAP Guidelines" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "K. Parikh" 1 => "M. Hall" 2 => "S.J. Teach" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Pediatrics" "fecha" => "2014" "volumen" => "133" "paginaInicial" => "1" "paginaFinal" => "7" ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0215" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Management of bronchiolitis in the emergency department: impact of evidence-based guidelines?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "L.W. Johnson" 1 => "J. Robles" 2 => "A. Hudgins" 3 => "S. Osburn" 4 => "D. Martin" 5 => "A. Thompson" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Pediatrics" "fecha" => "2013" "volumen" => "131" "numero" => "Suppl. 1" "paginaInicial" => "S103" "paginaFinal" => "S109" ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0220" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A clinical pathway for bronchiolitis is effective in reducing readmission rates" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. Cheney" 1 => "S. Barber" 2 => "L. Altamirano" 3 => "M. Cheney" 4 => "C. Williams" 5 => "M. Jackson" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Pediatr" "fecha" => "2005" "volumen" => "147" "paginaInicial" => "622" "paginaFinal" => "626" ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0225" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "An evidence-based clinical pathway for bronchiolitis safely reduces antibiotic overuse" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S.D. Wilson" 1 => "B.B. Dahl" 2 => "R.D. Wells" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Am J Med Qual" "fecha" => "2002" "volumen" => "17" "paginaInicial" => "195" "paginaFinal" => "199" ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0230" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Bronchiolitis in US emergency departments 1992 to 2000: epidemiology and practice variation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.M. Mansbach" 1 => "J.A. Emond" 2 => "C.A. Camargo" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Pediatr Emerg Care" "fecha" => "2005" "volumen" => "21" "paginaInicial" => "242" "paginaFinal" => "247" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23412879/0000009000000002/v1_201902020626/S2341287918302229/v1_201902020626/en/main.assets" "Apartado" => array:4 [ "identificador" => "26005" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Original Articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23412879/0000009000000002/v1_201902020626/S2341287918302229/v1_201902020626/en/main.pdf?idApp=UINPBA00005H&text.app=https://analesdepediatria.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341287918302229?idApp=UINPBA00005H" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 50 | 43 | 93 |
| 2024 September | 51 | 61 | 112 |
| 2024 August | 65 | 69 | 134 |
| 2024 July | 52 | 41 | 93 |
| 2024 June | 63 | 30 | 93 |
| 2024 May | 60 | 52 | 112 |
| 2024 April | 45 | 38 | 83 |
| 2024 March | 54 | 25 | 79 |
| 2024 February | 42 | 23 | 65 |
| 2024 January | 58 | 23 | 81 |
| 2023 December | 93 | 22 | 115 |
| 2023 November | 76 | 42 | 118 |
| 2023 October | 101 | 30 | 131 |
| 2023 September | 69 | 31 | 100 |
| 2023 August | 57 | 13 | 70 |
| 2023 July | 61 | 30 | 91 |
| 2023 June | 47 | 30 | 77 |
| 2023 May | 51 | 26 | 77 |
| 2023 April | 44 | 21 | 65 |
| 2023 March | 63 | 19 | 82 |
| 2023 February | 53 | 14 | 67 |
| 2023 January | 53 | 24 | 77 |
| 2022 December | 81 | 36 | 117 |
| 2022 November | 75 | 31 | 106 |
| 2022 October | 72 | 42 | 114 |
| 2022 September | 39 | 27 | 66 |
| 2022 August | 54 | 49 | 103 |
| 2022 July | 64 | 49 | 113 |
| 2022 June | 41 | 44 | 85 |
| 2022 May | 49 | 41 | 90 |
| 2022 April | 43 | 34 | 77 |
| 2022 March | 63 | 47 | 110 |
| 2022 February | 40 | 38 | 78 |
| 2022 January | 85 | 41 | 126 |
| 2021 December | 51 | 37 | 88 |
| 2021 November | 64 | 48 | 112 |
| 2021 October | 91 | 81 | 172 |
| 2021 September | 51 | 38 | 89 |
| 2021 August | 33 | 46 | 79 |
| 2021 July | 36 | 31 | 67 |
| 2021 June | 38 | 54 | 92 |
| 2021 May | 46 | 36 | 82 |
| 2021 April | 88 | 80 | 168 |
| 2021 March | 52 | 28 | 80 |
| 2021 February | 41 | 20 | 61 |
| 2021 January | 114 | 30 | 144 |
| 2020 December | 251 | 31 | 282 |
| 2020 November | 42 | 19 | 61 |
| 2020 October | 44 | 28 | 72 |
| 2020 September | 61 | 20 | 81 |
| 2020 August | 57 | 10 | 67 |
| 2020 July | 41 | 16 | 57 |
| 2020 June | 36 | 25 | 61 |
| 2020 May | 46 | 20 | 66 |
| 2020 April | 28 | 14 | 42 |
| 2020 March | 26 | 16 | 42 |
| 2020 February | 39 | 24 | 63 |
| 2020 January | 56 | 19 | 75 |
| 2019 December | 60 | 27 | 87 |
| 2019 November | 26 | 12 | 38 |
| 2019 October | 54 | 15 | 69 |
| 2019 September | 39 | 6 | 45 |
| 2019 August | 76 | 21 | 97 |
| 2019 July | 38 | 18 | 56 |
| 2019 June | 30 | 20 | 50 |
| 2019 May | 45 | 35 | 80 |
| 2019 April | 80 | 28 | 108 |
| 2019 March | 47 | 20 | 67 |
| 2019 February | 278 | 65 | 343 |
| 2019 January | 35 | 4 | 39 |
| 2018 December | 2 | 3 | 5 |
Show all
