Abstract
OBJECTIVE: The 2016 clinical practice guideline (CPG) replacing apparent life-threatening event (ALTE) with brief resolved unexplained event (BRUE) was associated with a reduction in hospitalizations and clinical testing among children with this condition in pediatric hospitals. However, as only a minority of acute-care encounters occur in dedicated pediatric centers, the overall effect of this CPG on children with ALTE/BRUE remains unknown. The purpose of this study is to examine changes in the diagnosis and management of BRUE in a statewide sample of non-pediatric hospitals following publication of the CPG. METHODS: This is a retrospective study of encounters of infants (<1 year) presenting to 178 non-pediatric illinois emergency departments (eds) between 2013 and 2019 with an international classification of disease (icd) 9th and 10th revision billing code of alte or brue (799.82, icd-9; r68.13, icd-10). our primary outcomes were counts of alte brue and the percent of patients with alte brue admitted and or transferred to another facility. our secondary outcome was clinical testing. we used interrupted time-series analysis for our primary outcome and chi-square testing for secondary outcomes. results were stratified into academic and community eds. results: this study included 4639 ed encounters for infants with brue that presented to academic eds (2229; 48.0%) or community eds (2410; 52.0%). at academic eds, alte brue diagnoses were increasing by 2.3 per quarter prior to the cpg publication and decreased by 0.5 per quarter after the cpg publication, representing a change in slope of -2.8 per quarter (p >< 0.01). the percent of alte brue patients admitted transferred was decreasing by 0.1% per quarter in the pre-intervention period and decreased by 0.3% per quarter in the post-intervention period, representing a change in slope of 0.7% (p =" 0.03)." at community eds, alte brue diagnoses were increasing by 2.9 per quarter prior to the cpg publication and increased by 1.4 per quarter after the cpg publication, a non-significant change in slope. the percent of alte brue patients admitted transferred was decreasing by 1.6% in the pre-intervention period and decreased by 0.9% in the post-intervention period, a non-significant change in slope. at academic eds, there was no significant change in clinical testing. at community eds, a lower proportion of patients in the post-intervention period had chest radiographs, blood cultures, metabolic panels, blood counts, and urine testing, while a higher proportion had pertussis testing and respiratory pathogen testing. conclusions: counts of brue diagnoses and the overall proportion of children admitted or transferred showed a consistent decrease at academic eds but had a nonsignificant change in trend at community eds following the cpg publication in 2016. there was no significant change in clinical testing at academic eds while community eds had a significant decrease in some testing and an increase in other types of testing. our findings suggest the need for greater implementation efforts in non-pediatric settings, specifically community eds, where pediatric patients with brue present infrequently in order to optimize care for these children.>
