Improving the management of infants with bronchiolitis in acute care settings: understanding factors that influence variations in practice to design tailored knowledge translation interventions.

Libby Haskell for Paediatric Research in Emergency Departments International Collaborative (PREDICT)

Introduction Tamaki Makaurau - Auckland

Rangitoto Island

Starship Children’s Health

• Background

• Qualitative study and findings • Designing interventions for change

• Where to from here

Outline of talk

Viral lower respiratory tract infection (<1 year of age) Clinical diagnosis based on typical history and exam Typically begins with URTI symptoms followed by onset of

respiratory distress, fever and one or more of: Cough Tachypnoea Retractions Widespread crackles and wheeze

What is bronchiolitis?

Peak severity is around day 2-3 Resolution over 1-10 days Cough may persist for weeks Commonly occurs in winter, but can present throughout the

year

What is bronchiolitis?

Bronchiolitis – the issues • Most common reason for infants <1 year of age to

be hospitalised

• Aboriginal and Torres Strait Islander peoples and Māori in New Zealand are disproportionately represented

• Management is supportive

• High level evidence of no benefit from: – Salbutamol – Chest x-ray – Antibiotics – Steroids – Adrenaline

Background continued

• Significant variation in practice across Australasia • 27-48% of >3500 infants admitted received at least one

therapy known to be of no benefit

• Australasian bronchiolitis guideline developed and

released in 2016

Need to: • Understand the behaviour you want to change

• Know why you want to change it

• Understand how behaviour changes

So how do we change behaviour?

Designing a target theory-informed Knowledge Translation intervention

Identify key evidence

based behaviours

Explore factors influencing behaviours

Develop a targeted, theory informed

intervention

Who needs to do what?

What are they doing and why?

What would work and how would it

work?

Systematic review

Qualitative interviews

Theoretically derived BCT Matrix

Cochrane EPOC reviews

Michie et al. From Theory to Intervention: Mapping Theoretically Derived Behavioural Determinants to Behaviour Change Techniques. Applied Psychology 2008, 57 (4): 660-80

Qualitative study • Semi-structured interviews

• 11 doctors, 9 nurses • Australia and New Zealand • Metropolitan/Regional • Medical/Nursing • Mixed/Paediatric Emergency Departments • Inpatient areas

• Factors that influence management of bronchiolitis

• Analysis using Theoretical Domains Framework

RESULTS: CXR

“I think they’re worried about deterioration and missing something”.

Consultant, Metropolitan, Paediatric ED, NZ.

Key influencing factor Belief about consequences Knowledge Social influences Environmental context and resources Skills

RESULTS: CXR

“It’s probably a bit of lack of knowledge and lack of experience; you’ve not seen

enough, you’re just worried. They can look quite bad and you are in a position where you don’t really want to miss something,

although you’ve really got nothing to miss”.

Registrar, Paediatric ED (Adult/paediatric trainee), NZ.

Key influencing factor Belief about consequences Knowledge Social influences Environmental context and resources Skills

RESULTS: CXR

“So there are parents that come in with expectations”.

Registrar, General Paeds, Metropolitan, Australia.

Key influencing factor Belief about consequences Knowledge Social influences Environmental context and resources Skills

RESULTS: CXR

“Perhaps, maybe the time pressure of needing to make an assessment,

is this bronchiolitis or is it something else?”

Consultant, General Paediatrics, Regional, Australia.

Key influencing factor Belief about consequences Knowledge Social influences Environmental context and resources Skills

RESULTS: CXR

“You can see why they do plunge in for x-ray straight away ‘cause that’s happened

in an adult which is where a lot of these trainees are coming from is just seeing

adults and haven’t really actually seen a lot of these little ones.”

Consultant, General Paediatrics, Regional, NZ.

Key influencing factor Belief about consequences Knowledge Social influences Environmental context and

resources Skills

RESULTS: Salbutamol

“If someone can be made better and go home, then it’s worth trying”.

Consultant, Paediatric ED, Metropolitan, Australia.

“You’re not going to necessarily run into harm by giving it a try.”

Consultant, General Paediatrics, Metropolitan, Australia.

Key influencing factor Belief about consequences Knowledge Social professional roles Social influences

RESULTS: Salbutamol

“Because most of us don’t at a more senior level, if we see a deteriorating

bronchiolitis, we’re more willing to accept that as progression of the underlying

condition, as opposed to lack of treatment with salbutamol”.

Consultant, General Paediatrics, Metropolitan, NZ.

Key influencing factor Belief about consequences Knowledge Social professional roles Social influences

RESULTS: Salbutamol

“So they often asked, ‘Have you tried salbutamol?”’ (when discussing referring

for inpatient care). Registrar, ED (mixed ED), Regional, NZ.

Key influencing factor Belief about consequences Knowledge Social professional roles Social influence

RESULTS: Salbutamol

“I think the commonest reason for its use, well, the two things is people wanting to

give them something, so parental pressure and clinicians’ internal pressure to give

some kind of treatment for an illness that there is actually no additional treatment for and misunderstanding about the idea

that it’s not actually salbutamol responsive wheeze.”

Consultant, ED (mixed), Regional, NZ.

Key influencing factor Belief about consequences Knowledge Social professional roles Social influence

Findings as per TDF - Cane 2012

Knowledge

Behavioural regulation

Emotion

Social influences

Environmental context and resources Memory, attention and decision processes

Goals

Intentions

Reinforcement

Beliefs about consequences

Optimism

Beliefs about capabilities

Social/professional role and identity

Skills

Where to from here…. Knowledge Translation bronchiolitis project

Objective: To determine whether tailored, theory informed KT intervention is effective in decreasing the use of therapies known to be of no benefit in infants less than 1 years with bronchiolitis, compared to passive dissemination of a bronchiolitis guideline. Design: A multi-centre cluster randomised controlled trial. Participants: 26 sites stratified by country and tertiary/secondary paediatric care provider to control or intervention arm. Time frame: 2 years, commenced 2016.

Summary

• Bronchiolitis is a significant health issue with disproportionate numbers of Aboriginal and Torres Strait Islander + Maori affected

• Variation in practice across Australasia

• Designing tailored, theory informed KT interventions is more likely to change practice

• Ultimate goal is improving care of infants with bronchiolitis

Investigators and affiliations Libby Haskell1,2 Emma Tavender3 Catherine Wilson3 Sharon O’Brien4 Meredith Borland4 Nicolette Sheridan2 Ed Oakley3,5 Stuart Dalziel1,2 for PREDICT6 1Starship Children’s Hospital, Auckland, New Zealand 2University of Auckland, Auckland, New Zealand 3Murdoch Childrens Research Institute, Melbourne, Australia 4Princess Margaret Hospital for Children, Perth, Australia 5The Royal Children’s Hospital, Melbourne, Australia 6Paediatric Research in Emergency Departments International Collaborative, Melbourne, Australia