This is another one of those window-to-the-future articles, where an enterprising department has taken a commonplace disease with a relatively high admission rate and tried to change the status quo.
As they note, bronchiolitis is the #1 cause of admission for children < 1 year, it accounts for 150,000 admissions annually, and costs $500 million. One of the key clinical features that keeps otherwise well-appearing children in the hospital is hypoxia, specifically < 90% saturation by pulse oximetry as recommended by the American Academy of Pediatrics.
This is a retrospective chart review that essentially says “we did this and we like it.” 4,194 relevant charts were reviewed, 57% of which were discharged without home oxygen, 15% were discharged on oxygen, and 28% were admitted. Of the discharged patients, 4% of the no-home-oxygen patients returned for eventual admission compared with 6% of the discharge-on-oxygen patients. Overall, this led to a 25% relative decrease in admissions for bronchiolitis at their institution, compared to historical controls.
More confirmatory study is needed – it’s a little different at mile-high Denver than the rest of the U.S. – but this may be a promising way to reduce admissions for bronchiolitis. It is also suggestive of what is likely the new future of cost-containment medicine, at least where the malpractice environment will tolerate it – an increasing proportion of higher-risk discharges with, in theory, closer follow-up that saves money in the long run.
“Discharged on Supplemental Oxygen From an Emergency Department in Patients With Bronchiolitis”
http://www.ncbi.nlm.nih.gov/pubmed/22331343
Interesting concept- we should make sure that it is well studied before being applied because changing all of these traditionally inpatient diseases to outpatient treatment increases our liability as EM physicians. On the other hand- I think we do need to start being more fiscally responsible as a healthcare system and treating more diseases as an outpatient could be the way to go. However- a European study on treating PE as an outpatient showed that the cost savings of preventing admission were wiped out by the home healthcare that was required.
Also- I know that the recommendations are to hospitalize for low sats but has anyone shown this to be of benefit anyway? Isn't a sat of 90 relatively made up? Has anyone shown a benefit from in-hospital oxygen in these borderline kids? I say borderline because its almost always 88-89% sats- anything lower has us way more concerned- which mean that we are treating numbers. These are all questions that will probably never be adequately answered but we should at least recognize that most of the kids in the low sat group would go home and do fine without oxygen anyway and just some bulb suctioning.
Interesting concept- we should make sure that it is well studied before being applied because changing all of these traditionally inpatient diseases to outpatient treatment increases our liability as EM physicians. On the other hand- I think we do need to start being more fiscally responsible as a healthcare system and treating more diseases as an outpatient could be the way to go. However- a European study on treating PE as an outpatient showed that the cost savings of preventing admission were wiped out by the home healthcare that was required.
Also- I know that the recommendations are to hospitalize for low sats but has anyone shown this to be of benefit anyway? Isn't a sat of 90 relatively made up? Has anyone shown a benefit from in-hospital oxygen in these borderline kids? I say borderline because its almost always 88-89% sats- anything lower has us way more concerned- which mean that we are treating numbers. These are all questions that will probably never be adequately answered but we should at least recognize that most of the kids in the low sat group would go home and do fine without oxygen anyway and just some bulb suctioning.