Reducing unnecessary chest X-rays, antibiotics and bronchodilators through implementation of the NICE bronchiolitis guideline


Chest X-rays (CXR), antibiotics and inhaled/nebulized therapy are overused in bronchiolitis, despite evidence-based guidelines suggesting supportive management only. This study investigates the effect of the implementation of the NICE bronchiolitis guideline in a secondary paediatric unit in England. We present a quality improvement project with a completed audit cycle (winter 2014–2015 and 2015–2016) pre- and post-implementation of the NICE bronchiolitis guideline. The educational intervention included sessions for raising awareness of appropriate and inappropriate management of bronchiolitis for both clinicians and nursing staff. As a result, the number of chest radiographs reduced fivefold (from 20 to 4% of patients, absolute reduction 16%), antibiotics reduced more than threefold (from 22 to 6% of patients, absolute reduction 16%) and inhaled/nebulised treatment up to twofold (from 30 to 16%, absolute reduction 14%). Overall NICE guideline compliance rose from 28 to 63%.

Conclusion: Implementation of the NICE bronchiolitis guideline supported by a simple educational intervention can effectively reduce the number of inappropriate chest radiographs and antibiotic prescribing in bronchiolitis, and enhance compliance with the NICE guideline.

What is Known:
• Bronchiolitis management in paediatric units in the UK is variable, with poor evidence for existing guidance. Best available evidence was compiled into the NICE guideline, aiming to standardize care.
• Some evidence exists for the effectiveness of quality improvement approaches to improve the management of bronchiolitis.
What is New:
• NICE guidance can be effectively applied to a department using simple educational tools.
• Effective NICE implementation reduces the rates of unnecessary chest radiograph and antibiotic administration for patients admitted with bronchiolitis in District General Hospitals.

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95% confidence intervals


Clinical Effectiveness Unit


Chest X-ray


Hypertonic saline (for nebulisation)


Lower respiratory tract infection


National Institute for Clinical Excellence


Odds ratio


Paediatric day unit


Paediatric inpatient ward


Respiratory syncytial virus


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The authors are most grateful to James Andrew, Terry Holdcroft and John Blenkinsopp from the Clinical Effectiveness Unit at University Hospital North Tees for their support (randomization of patients in the 2014-2015 season, providing patient data and support in analysis of data for both seasons).

Author information




All authors contributed significantly to this study. RB, BT, JC and CH equally perceived the idea and concept, designed the methods, collected, analysed and interpreted the data, wrote and critically reviewed the manuscript. All authors approved the final version of the manuscript for submission. CH is the guarantor of this study.

Corresponding author

Correspondence to Christian Harkensee.

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Conflict of interest

The authors declare that they have no conflict of interest.

Informed consent

This study is a completed audit cycle within the scope of internal quality improvement and clinical governance and was as such formally improved internally, with no requirement for formal ethical approval or informed consent.

Additional information

Communicated by Peter de Winter

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Breakell, R., Thorndyke, B., Clennett, J. et al. Reducing unnecessary chest X-rays, antibiotics and bronchodilators through implementation of the NICE bronchiolitis guideline. Eur J Pediatr 177, 47–51 (2018).

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  • Bronchiolitis
  • Infant
  • Secondary care
  • Clinical quality improvement
  • Respiratory syncytial virus
  • Guideline
  • Antibiotic therapy
  • Radiology investigations