Bronchiolitis is nasty stuff. An estimated one in five infants - most commonly three to six months old - each year suffer from the virus-caused infection of the lower airways. Swollen and clogged with mucus, they can't breathe, often can't eat and they cry ... and cry. 

The babies are miserable, and so are their parents. But studies have found that X-rays, steroids and bronchodilators - medicines such as albuterol - don't do much to diagnose or resolve the condition. "There is no magical drug," said Diana Mark, clinical specialist for respiratory care for pediatrics at Wesley Medical Center. The best medicine is to suction the airways (essentially vacuuming out the mucus) and wait it out, as research has found and American Academy of Pediatrics guidelines recommend.

But, as is often the case with guidelines and protocols, ensuring that the recommendations are universally followed across the board can be difficult. 

At Wesley, Dr. Stephanie Kuhlmann, a pediatric hospitalist and associate professor at KU School of Medicine-Wichita, is working with Mark and others to put those recommendations into practice as part of a national quality improvement collaborative involving about four dozen hospitals nationwide. The collaborative is supported by the Value in Inpatient Pediatrics Network (VIP), made up of 160 hospitals in four countries. It's part of a broader effort by the American Academy of Pediatrics to use measures and quality improvement processes to implement guidelines more effectively and improve care across the country.

Wesley has been selected as a network site for three projects, two involving bronchiolitis and another covering first-time urinary tract infections in children.

"It's an honor to be chosen to participate," Kuhlmann said. "It speaks highly of the team we have working on these projects. They can see we have invested folks with the appropriate resources."

"Wichita and KU should be proud to have a team dedicated to this work," said Dr. Brian Pate, chair of the Department of Pediatrics at KU School of Medicine-Wichita. Pate is a founder of the VIP Network and a member of its steering committee.

What the effort entails

Mark, the clinical respiratory specialist on the team, said the bronchiolitis projects have built upon efforts already in place at Wesley.

Using bronchodilators, for example, although not part of the hospital's protocol, is now entirely off the table as an option except for rare cases. The same is true for steroids, chest X-rays, viral screening and oxygen saturation monitoring, all of which the national guideline identifies as procedures or treatments that should be reduced because they don't help diagnose or treat bronchiolitis and result in unnecessary care, expense and prolonged hospital stays.

At the hospital, there's been greater emphasis on suctioning babies for relief on both an inpatient and outpatient basis, and on better explaining the condition and treatments to providers and parents. "We do more education about the disease, how to suction the baby at home, and if they are hospitalized we explain why we're not giving medications," Mark said.

Another component is having a discussion with parents about smoking cessation, as tobacco use can contribute to the severity of bronchiolitis.

The project "limits exposure to X-rays and medicines that aren't beneficial to our patients," Kuhlmann said. "We don't need to use those treatments."

As a participant in the multi-site projects, the Wesley team works to institute goals - such as a 50 percent chest X-ray reduction - and collect data that it sends to the VIP Network, which provides feedback on the Wichita effort. After taking part in the initial bronchiolitis project, the Wesley team became involved in one targeting the emergency department. The intent is to ensure that infants treated there receive the same care - avoiding X-rays and bronchodilators - from ER doctors that they would from a pediatric hospitalist.

"VIP targets hospitalists working in small children's hospitals or in community hospitals, because 70 percent of kids in the U.S. are admitted to community-based hospitals. They've filled a wonderful niche," said Dr. Stephen Kairys, a New Jersey pediatrician who is medical director for the Quality Improvement Innovation Networks, the umbrella group for VIP.

The filter-down challenge

Whether it's treatment of asthma, urinary tract infections or one of many other conditions, moving information from the research stage to the patient-care level can be a slow process. Reducing that unnecessary care is a primary goal of the network.

"We're constantly learning about better treatments, but we can't figure out how to get people to do them," Kairys said. "It takes 18 or 19 years for an evidence-based concept to actually make it into the practice of medicine. It's been 25 years since the asthma guidelines came out and there are still large numbers of doctors and pediatricians who treat asthma improperly."

"I hope they reduce that lag time to four or five years."

The educational component

Improved quality of care is one benefit of the program. Education is another, as pediatrics and other residents see evidence-based medicine being implemented.

"It's really good for them to see we are always improving our practice and that we are a part of a bigger system, that it's a national effort, and that our facility values being part of the process," Mark said.

"One of the main reasons we built VIP," Pate said, "is to transform the evidence and words in a guideline to metrics that can be measured to demonstrate how well a system is using the guideline, and then to objectively track the impact of interventions to improve care." 

"The bottom line," Kuhlmann said, "is that we're teaching quality care to our residents and students. And our young patients have better outcomes."