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Introduction to the B-QIP Change Package. Presenters: Michelle Marks, DO, FAAP Cleveland Clinic Children’s Hospital Grant Mussman, MD, FAAP Cincinnati Children’s Hospital B-QIP Learning Session Webinar August 29, 2013. Agenda. Introductions. Michelle Marks, DO, FAAP

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introduction to the b qip change package

Introduction to the B-QIP Change Package


Michelle Marks, DO, FAAPCleveland Clinic Children’s Hospital

Grant Mussman, MD, FAAP

Cincinnati Children’s Hospital

B-QIP Learning Session Webinar

August 29, 2013

  • Michelle Marks, DO, FAAP

Cleveland Clinic Children’s Hospital

  • Grant Mussman, MD, FAAP

Cincinnati Children’s Hospital

Reminders: This webinar is being recorded. If you are a local physician leader seeking ABP MOC Part 4, please identify yourself via the Question chat box.

The Quality Collaborative for Improving Hospitalist Compliance with the AAP Bronchiolitis Guideline (B-QIP) is funded by the AAP Quality Improvement Innovation Networks (QuIIN)

learning objectives
Learning Objectives

By the end of this webinar, you will be able to:

Integrate, improve and test respiratory scores in the treatment of bronchiolitis

Draft, adapt and test protocols or ordersets related to bronchiolitis treatment

Know where to look for resources to help improve inter-departmental communication, tobacco screening and treatment, and other best practices


Right now you should be gathering your data from last bronchiolitis season

  • You should feel like you understand the measures we will be tracking for BQIP
  • You should have a sense of who makes up your team
  • Today you will be introduced to some potential tools
  • You will look at your local data and your current practices
  • You and your team will pick an intervention strategy with a goal to implement it before Jan 2014

Where are we now?

Where am I going?

b qip change package outline
B-QIP Change Package Outline

The change package is not an exhaustive list of tools. It is merely a starting point of tools and strategies that can be adapted. The B-QIP coaching team is in support of you continuing to use strategies that work; please do share those strategies with your peer teams!

The change package is a resource…we are sure you are already on the improvement journey!

b qip change package outline cont d
B-QIP Change Package Outline, cont’d
  • Organized by:
    • Clinical pathway
    • Respiratory Distress Score
    • Oxygen Weaning Protocol
    • Tobacco Smoke Exposure
    • Other Tools & References
integration of respiratory scores into treatment
Integration of Respiratory Scores into treatment
  • Ideal Respiratory Score
    • Simple
      • Enough elements to fully capture respiratory status but only just enough
      • Usable by variety of clinical providers
    • Reliable
    • Responsive
  • WARM score
    • Adapted from the WARM-E asthma score developed at Cincinnati Children’s Hospital
warm score
WARM score
  • Wheezing (0-2)
      • None
      • End expiratory
      • Entire/any expiratory
  • Air Exchange (0-2)
      • Normal (0)
      • Focal decrease (1)
      • More than one area of decrease (2)
  • Respiratory Rate (0-1)
      • Above age-normalized tachypnea threshold (1)
  • Muscle Use/Retractions (0-2)
      • None (0)
      • Subcostal/Intercostal (1)
      • Any neck or abdominal (2)
warm score1
WARM score
  • Score is additive, ranging from 0 to 7
  • Lower score = less sick
  • For scores > 3, a trial of bronchodilator may be indicated
    • Reasonable to try suctioning of the nasopharynx first and then re-score
  • Improvement after bronchodilator
    • WARM decreased by 2 or more points
    • Can continue PRN bronchodilator
    • Avoid multiple trials without demonstrated improvement
scenario 1
Scenario 1
  • 6 month old infant with URI symptoms and fever
    • On exam in the ED: tachypneic with moderate retractions but little wheezing
    • Admitted with mild O2 requirement
    • At sign-out, ED physician reports that patient seemed to have responded to two albuterol treatment and is more comfortable now
scenario 12
Scenario #1
  • No change in respiratory score noted before or after albuterol treatment
  • Further bronchodilator trials unnecessary
  • Differences in patient “comfort” can be perceived for a variety of reasons
    • Control of fever
    • Suctioning
    • Oxygen
    • Mobilization of mucus plug
scenario 2
Scenario #2
  • 6 month old infant with URI symptoms and fever
  • On exam in the ED: tachypnea, retractions, head bobbing, and nasal flaring
  • Suctioned once and then given an albuterol treatment, now has much easier WOB
  • Admitted with mild O2 requirement
scenario 22
Scenario #2
  • Respiratory score actually increases after bronchodilator trial (increased tachypnea)
  • Further bronchodilator trials unnecessary
  • Patient did benefit significantly from suctioning
scenario 3
Scenario #3
  • 6 month old infant with URI symptoms and increased work of breathing
  • On exam in the ED: mildly tachypneic, no retractions, scattered wheezing
  • Admitted with mild O2 requirement
scenario 32
Scenario #3
  • Mild symptoms and WARM < 3
  • Bronchodilator trial not indicated
scenario 3 continued
Scenario #3: Continued
  • Now 12 hours after admission, and nurse calls to report that patient afebrile but slightly more tachypneic, with retractions and wheezing
  • WARM score from RT as follows:
scenario 3 continued1
Scenario #3: Continued
  • No response to suctioning on the floor
  • WARM score > 3
  • Bronchodilator trial indicated at this point
scenario 3 continues
Scenario #3: Continues
  • Patient admitted with PRN albuterol available
  • Twenty minutes after the treatment ends, the nurse again calls with a concern for the same patient
  • Oxygen requirement has increased from 0.5 liters to 2 liters by nasal cannula
  • Wheezing and retractions have returned
  • Suctioning ineffective once again
scenario 33
Scenario #3
  • A second bronchodilator has been administered
scenario 3 conclusion
Scenario #3: Conclusion
  • Bronchodilators not helping at this point
    • Lack of response clearly documented
  • Suctioning also not providing benefit
  • Time to do something else!
    • Call the PICU
    • Initiate high flow nasal cannula on the floor (if available on the floor)
  • WARM score is a simple, reliable, and responsive method of objectively assessing response to bronchodilators and suctioning
    • Respiratory therapists can reliably administer and document the score
  • Threshold score of 3 identifies those who may benefit from a bronchodilator trial
  • A decrease of 2 or more in WARM score indicates response to therapy
    • Bronchodilators available PRN to responders
qi concept ordersets guidelines protocols
QI concept: ordersets/guidelines/protocols
  • Shared baseline
  • Intended to provide ideal care for the “routine” patient
  • Educate users regarding evidence for care thus promoting change
  • Decrease variation in care


  • Unit secretary notifies Respiratory Therapist (RT) assigned to that pediatric area when a patient is admitted with orders for Bronchiolitis Protocol.
  • Orders for Q4 Hypertonic will be placed in Cerner.
  • Patient will be assessed and score.
  • Score < 3 no intervention
  • Score >2 patient will be nasally suctioned and wait at least 5 minutes and then scored again.
    • Score >3 give treatment of Hypertonic Saline only, unless patient meets exclusion criteria.
  • Score again 15-30minutes after treatment positive response ( decrease in score by 2 or more)
  • If score increase by 2 or more on just hypertonic give albuterol and add albuterol to hypertonic saline treatments.
  • Do treatment Q4 x 3 and if score decrease by 2 or more, space to Q6x 2.
  • If patient does not respond after third Q4 treatment (score that does not decrease by 2 or more or increase no more treatments given).
  • If patient score < 4 for 24 hours treatments are discontinued.

Patient admitted for Bronchiolitis

Bronchiolitis Care Path

Nasal tracheal suctioning with normal saline drops performed for all patients

Oxygenation Assessed - Administer O2 by nasal cannula for SpO2 < 91 % or increased work of breathing

Clinical Assessment repeated following suctioning and O2 administration

If scored > 3, Aerosol treatment (Racemic epi) should be administered x 1

Responsive as evidenced by improvement in clinical score

If unresponsive to Racemic epi treament

Assess every 2 hours with continued aerosol treatments of Racemic epi if clinical scores greater than 3

Consider Albuterol or Levabuterol for patients with responsive wheezing (patients with history of RAD)

Responsive to Albuterol/Levalbuterol

Unresponsive to Albuterol /Levalbuterol

Discontinue all inhaled medications if patient is non-responsive as evidenced by the bronchiolitis clinical assessment score

Assess every 2 hours with continued treatments of Albuterol/Levalbuterol for clinical scores greater than 3


Difficulty getting consensus

  • Desire for perfection
  • Lack of understanding of QI/process improvement cycle
  • Lack of evidence to support recommendations
b qip asks
  • Review current order sets and guidelines for needed updates and streamlining
  • Do your current resources address all the elements of the project ??(particularly tobacco)