Predicting escalated care in infants with bronchiolitis

Gabrielle Freire, Nathan Kuppermann, Roger Zemek, Amy C. Plint, Franz E. Babl, Stuart R. Dalziel, Stephen B. Freedman, Eshetu G. Atenafu, Derek Stephens, Dale W. Steele, Ricardo M. Fernandes, Todd Adam Florin, Anupam Kharbanda, Mark D. Lyttle, David W. Johnson, David Schnadower, Charles G. Macias, Javier Benito, Suzanne Schuh*

*Corresponding author for this work

Research output: Contribution to journalArticle

4 Citations (Scopus)

Abstract

BACKGROUND AND OBJECTIVES: Early risk stratification of infants with bronchiolitis receiving airway support is critical for focusing appropriate therapies, yet the tools to risk categorize this subpopulation do not exist. Our objective was to identify predictors of "escalated care" in bronchiolitis. We hypothesized there would be a significant association between escalated care and predictors in the emergency department. We subsequently developed a risk score for escalated care. METHODS: We conducted a retrospective cohort study of previously healthy infants aged <12 months with bronchiolitis. Our primary outcome was escalated care (ie, hospitalization with high-flow nasal cannula, noninvasive or invasive ventilation, or intensive care admission). The predictors evaluated were age, prematurity, day of illness, poor feeding, dehydration, apnea, nasal flaring and/or grunting, respiratory rate, oxygen saturation, and retractions. RESULTS: Of 2722 patients, 261 (9.6%) received escalated care. Multivariable predictors of escalated care were oxygen saturation <90% (odds ratio [OR]: 8.9 [95% confidence interval (CI) 5.1-15.7]), nasal flaring and/or grunting (OR: 3.8 [95% CI 2.6-5.4]), apnea (OR: 3.0 [95% CI 1.9-4.8]), retractions (OR: 3.0 [95% CI 1.6-5.7]), age ≤2 months (OR: 2.1 [95% CI 1.5-3.0]), dehydration (OR 2.1 [95% CI 1.4-3.3]), and poor feeding (OR: 1.9 [95% CI 1.3- 2.7]). One of 217 (0.5%) infants without predictors received escalated care. The risk score ranged from 0 to 14 points, with the estimated risk of escalated care from 0.46% (0 points) to 96.9% (14 points). The area under the curve was 85%. CONCLUSIONS: We identified variables measured in the emergency department predictive of escalated care in bronchiolitis and derived a risk score to stratify risk of this outcome. This score may be used to aid management and disposition decisions.

Original languageEnglish (US)
Article numbere20174253
JournalPediatrics
Volume142
Issue number3
DOIs
StatePublished - Sep 1 2018

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Infant Care
Bronchiolitis
Odds Ratio
Confidence Intervals
Apnea
Dehydration
Nose
Hospital Emergency Service
Oxygen
Sick Leave
Critical Care
Respiratory Rate
Area Under Curve
Ventilation
Hospitalization
Cohort Studies
Retrospective Studies

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health

Cite this

Freire, G., Kuppermann, N., Zemek, R., Plint, A. C., Babl, F. E., Dalziel, S. R., ... Schuh, S. (2018). Predicting escalated care in infants with bronchiolitis. Pediatrics, 142(3), [e20174253]. https://doi.org/10.1542/peds.2017-4253
Freire, Gabrielle ; Kuppermann, Nathan ; Zemek, Roger ; Plint, Amy C. ; Babl, Franz E. ; Dalziel, Stuart R. ; Freedman, Stephen B. ; Atenafu, Eshetu G. ; Stephens, Derek ; Steele, Dale W. ; Fernandes, Ricardo M. ; Florin, Todd Adam ; Kharbanda, Anupam ; Lyttle, Mark D. ; Johnson, David W. ; Schnadower, David ; Macias, Charles G. ; Benito, Javier ; Schuh, Suzanne. / Predicting escalated care in infants with bronchiolitis. In: Pediatrics. 2018 ; Vol. 142, No. 3.
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abstract = "BACKGROUND AND OBJECTIVES: Early risk stratification of infants with bronchiolitis receiving airway support is critical for focusing appropriate therapies, yet the tools to risk categorize this subpopulation do not exist. Our objective was to identify predictors of {"}escalated care{"} in bronchiolitis. We hypothesized there would be a significant association between escalated care and predictors in the emergency department. We subsequently developed a risk score for escalated care. METHODS: We conducted a retrospective cohort study of previously healthy infants aged <12 months with bronchiolitis. Our primary outcome was escalated care (ie, hospitalization with high-flow nasal cannula, noninvasive or invasive ventilation, or intensive care admission). The predictors evaluated were age, prematurity, day of illness, poor feeding, dehydration, apnea, nasal flaring and/or grunting, respiratory rate, oxygen saturation, and retractions. RESULTS: Of 2722 patients, 261 (9.6{\%}) received escalated care. Multivariable predictors of escalated care were oxygen saturation <90{\%} (odds ratio [OR]: 8.9 [95{\%} confidence interval (CI) 5.1-15.7]), nasal flaring and/or grunting (OR: 3.8 [95{\%} CI 2.6-5.4]), apnea (OR: 3.0 [95{\%} CI 1.9-4.8]), retractions (OR: 3.0 [95{\%} CI 1.6-5.7]), age ≤2 months (OR: 2.1 [95{\%} CI 1.5-3.0]), dehydration (OR 2.1 [95{\%} CI 1.4-3.3]), and poor feeding (OR: 1.9 [95{\%} CI 1.3- 2.7]). One of 217 (0.5{\%}) infants without predictors received escalated care. The risk score ranged from 0 to 14 points, with the estimated risk of escalated care from 0.46{\%} (0 points) to 96.9{\%} (14 points). The area under the curve was 85{\%}. CONCLUSIONS: We identified variables measured in the emergency department predictive of escalated care in bronchiolitis and derived a risk score to stratify risk of this outcome. This score may be used to aid management and disposition decisions.",
author = "Gabrielle Freire and Nathan Kuppermann and Roger Zemek and Plint, {Amy C.} and Babl, {Franz E.} and Dalziel, {Stuart R.} and Freedman, {Stephen B.} and Atenafu, {Eshetu G.} and Derek Stephens and Steele, {Dale W.} and Fernandes, {Ricardo M.} and Florin, {Todd Adam} and Anupam Kharbanda and Lyttle, {Mark D.} and Johnson, {David W.} and David Schnadower and Macias, {Charles G.} and Javier Benito and Suzanne Schuh",
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Freire, G, Kuppermann, N, Zemek, R, Plint, AC, Babl, FE, Dalziel, SR, Freedman, SB, Atenafu, EG, Stephens, D, Steele, DW, Fernandes, RM, Florin, TA, Kharbanda, A, Lyttle, MD, Johnson, DW, Schnadower, D, Macias, CG, Benito, J & Schuh, S 2018, 'Predicting escalated care in infants with bronchiolitis', Pediatrics, vol. 142, no. 3, e20174253. https://doi.org/10.1542/peds.2017-4253

Predicting escalated care in infants with bronchiolitis. / Freire, Gabrielle; Kuppermann, Nathan; Zemek, Roger; Plint, Amy C.; Babl, Franz E.; Dalziel, Stuart R.; Freedman, Stephen B.; Atenafu, Eshetu G.; Stephens, Derek; Steele, Dale W.; Fernandes, Ricardo M.; Florin, Todd Adam; Kharbanda, Anupam; Lyttle, Mark D.; Johnson, David W.; Schnadower, David; Macias, Charles G.; Benito, Javier; Schuh, Suzanne.

In: Pediatrics, Vol. 142, No. 3, e20174253, 01.09.2018.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Predicting escalated care in infants with bronchiolitis

AU - Freire, Gabrielle

AU - Kuppermann, Nathan

AU - Zemek, Roger

AU - Plint, Amy C.

AU - Babl, Franz E.

AU - Dalziel, Stuart R.

AU - Freedman, Stephen B.

AU - Atenafu, Eshetu G.

AU - Stephens, Derek

AU - Steele, Dale W.

AU - Fernandes, Ricardo M.

AU - Florin, Todd Adam

AU - Kharbanda, Anupam

AU - Lyttle, Mark D.

AU - Johnson, David W.

AU - Schnadower, David

AU - Macias, Charles G.

AU - Benito, Javier

AU - Schuh, Suzanne

PY - 2018/9/1

Y1 - 2018/9/1

N2 - BACKGROUND AND OBJECTIVES: Early risk stratification of infants with bronchiolitis receiving airway support is critical for focusing appropriate therapies, yet the tools to risk categorize this subpopulation do not exist. Our objective was to identify predictors of "escalated care" in bronchiolitis. We hypothesized there would be a significant association between escalated care and predictors in the emergency department. We subsequently developed a risk score for escalated care. METHODS: We conducted a retrospective cohort study of previously healthy infants aged <12 months with bronchiolitis. Our primary outcome was escalated care (ie, hospitalization with high-flow nasal cannula, noninvasive or invasive ventilation, or intensive care admission). The predictors evaluated were age, prematurity, day of illness, poor feeding, dehydration, apnea, nasal flaring and/or grunting, respiratory rate, oxygen saturation, and retractions. RESULTS: Of 2722 patients, 261 (9.6%) received escalated care. Multivariable predictors of escalated care were oxygen saturation <90% (odds ratio [OR]: 8.9 [95% confidence interval (CI) 5.1-15.7]), nasal flaring and/or grunting (OR: 3.8 [95% CI 2.6-5.4]), apnea (OR: 3.0 [95% CI 1.9-4.8]), retractions (OR: 3.0 [95% CI 1.6-5.7]), age ≤2 months (OR: 2.1 [95% CI 1.5-3.0]), dehydration (OR 2.1 [95% CI 1.4-3.3]), and poor feeding (OR: 1.9 [95% CI 1.3- 2.7]). One of 217 (0.5%) infants without predictors received escalated care. The risk score ranged from 0 to 14 points, with the estimated risk of escalated care from 0.46% (0 points) to 96.9% (14 points). The area under the curve was 85%. CONCLUSIONS: We identified variables measured in the emergency department predictive of escalated care in bronchiolitis and derived a risk score to stratify risk of this outcome. This score may be used to aid management and disposition decisions.

AB - BACKGROUND AND OBJECTIVES: Early risk stratification of infants with bronchiolitis receiving airway support is critical for focusing appropriate therapies, yet the tools to risk categorize this subpopulation do not exist. Our objective was to identify predictors of "escalated care" in bronchiolitis. We hypothesized there would be a significant association between escalated care and predictors in the emergency department. We subsequently developed a risk score for escalated care. METHODS: We conducted a retrospective cohort study of previously healthy infants aged <12 months with bronchiolitis. Our primary outcome was escalated care (ie, hospitalization with high-flow nasal cannula, noninvasive or invasive ventilation, or intensive care admission). The predictors evaluated were age, prematurity, day of illness, poor feeding, dehydration, apnea, nasal flaring and/or grunting, respiratory rate, oxygen saturation, and retractions. RESULTS: Of 2722 patients, 261 (9.6%) received escalated care. Multivariable predictors of escalated care were oxygen saturation <90% (odds ratio [OR]: 8.9 [95% confidence interval (CI) 5.1-15.7]), nasal flaring and/or grunting (OR: 3.8 [95% CI 2.6-5.4]), apnea (OR: 3.0 [95% CI 1.9-4.8]), retractions (OR: 3.0 [95% CI 1.6-5.7]), age ≤2 months (OR: 2.1 [95% CI 1.5-3.0]), dehydration (OR 2.1 [95% CI 1.4-3.3]), and poor feeding (OR: 1.9 [95% CI 1.3- 2.7]). One of 217 (0.5%) infants without predictors received escalated care. The risk score ranged from 0 to 14 points, with the estimated risk of escalated care from 0.46% (0 points) to 96.9% (14 points). The area under the curve was 85%. CONCLUSIONS: We identified variables measured in the emergency department predictive of escalated care in bronchiolitis and derived a risk score to stratify risk of this outcome. This score may be used to aid management and disposition decisions.

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Freire G, Kuppermann N, Zemek R, Plint AC, Babl FE, Dalziel SR et al. Predicting escalated care in infants with bronchiolitis. Pediatrics. 2018 Sep 1;142(3). e20174253. https://doi.org/10.1542/peds.2017-4253