Program addressed unnecessary x-ray use without increasing 72-hour returns to ED

In an effort to reduce the overuse of chest radiographs (CXRs) for children with bronchiolitis, researchers crafted a program of high reliability interventions that brought about significant, sustained reductions and that were more effective than educational campaigns without increasing return visits to the emergency department (ED) within 72 hours.

Their results are published in Pediatrics.

“A cost-effectiveness analysis of the use of radiography in bronchiolitis revealed savings, without compromising diagnostic accuracy for alternate diagnoses, such as bacterial pneumonia. Although pediatric emergency departments (EDs) have fared better than general EDs in chest radiograph (CXR) use, use within pediatric hospitals continues to remain high, with reported averages ranging from 42% to 55%,” wrote S. Barron Frazier, MD, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, and colleagues.

“Bronchiolitis is a leading cause of pediatric hospitalization in the United States, resulting in significant morbidity and health care resource use. Despite American Academy of Pediatrics recommendations against obtaining chest radiographs (CXRs) for bronchiolitis, variation in care continues. Historically, clinical practice guidelines and educational campaigns have had mixed success in reducing unnecessary CXR use. Our aim was to reduce CXR use for children <2 years with a primary diagnosis of bronchiolitis, regardless of emergency department (ED) disposition or preexisting conditions, from 42.1% to <15% of encounters by March 2020,” they added.

To do this, they created a multidisciplinary team in 2012 with the goal of standardizing bronchiolitis care. The team included nurse educators, pediatric emergency medicine (PEM) trained and hospitalist physicians, a PEM fellow, respiratory therapists, and pediatric residents. The primary outcome was the percent of bronchiolitis encounters with a CXR. The balancing measure was return visits within 72 hours to the ED.

“From previous CXR work done at our institution for asthma, we also learned that providing specific reasons to order a CXR in place of general recommendations had a stronger impact on provider behavior. Rather than simply discouraging CXRs for bronchiolitis in general, the team created a list of indications for CXRs, including persistent focal lung findings, airway compromise, worsening condition, and new murmur,” explained Frazier and colleagues, who also developed and implemented a control chart to help assess the use of chest radiographs over time.

Between 2012 to 2020, Frazier and colleagues identified 12,120 cases of bronchiolitis. Chest radiograph use was 42.1% at pre-implementation baseline, and 3,635 CXRs were ordered. Educational campaigns to improve the use of chest radiographs were conducted in October 2013 and during the winter months of 2016-2017. No significant reductions in the use of chest radiographs occurred as a result of these initial measures.

In 2015, a separate quality improvement project directed towards reducing the use of CXRs in managing asthma had removed CXR as a default option in a frequently used dyspnea order set. This unrelated project would have significant effects on the use of CXRs in patient with bronchiolitis, eventually reducing use of CXRs to 23.3%.

In July 2017, researchers specifically created a chest-x-ray-specific team, and then, in 2018, introduced changes to the clinical practice guidelines (CPGs), which included more user-friendly formatting and respiratory distress scoring to define the severity of bronchiolitis.

“Rather than simply discouraging CXRs for bronchiolitis in general, the team created a list of indications for CXRs, including persistent focal lung findings, airway compromise, worsening condition, and new murmur,” they explained.

In April 2018, the team designed a modified electronic ordering infrastructure that included a bronchiolitis order for both ED and patient settings (considered a level 2 reliability intervention). Best practice advisory (BPA) alerts were also created for unwarranted tests or therapies in patients with a charted diagnosis of bronchiolitis in the EMR or in whom the inpatient bronchiolitis order set was used (considered a level 3 reliability intervention).

As a result of these high-reliability interventions, the mean usage of CXRs in these patients was again reduced to 18.9%, which was sustained for 20 months.

“A retrospective review revealed that the care of discharged patients from the ED was significantly impacted by the dyspnea order set modification, with a reduction in CXR use from 32.9% to 15.2%, and the ED order set and BPA alert interventions again reduced ED treat-and-release use to 9%. Inpatient use decreased from 62.5% to 35.1%, associated with the removal of the dyspnea order set,” wrote Frazier and colleagues.

They found no changes in return within 72 hours in the children who were initially discharged from the ED with a diagnosis of bronchiolitis.

“The impact of high-reliability interventions, applied through [quality improvement] methodology, were associated with significant, sustained reductions in CXR use and were more effective than educational campaigns. Successful implementation of CPGs may rely more heavily on workflow redesign and less on educational campaigns in the hospital setting. Reliance on higher reliability interventions instead of education alone may provide other institutions an improved opportunity to reduce overuse and improve care for children at their hospitals,” concluded Frazier and colleagues.

Study limitations include the nongeneralizability of these results to all institutes, the inaccuracies inherent in identifying patients only through billing codes, preexisting conditions in some children, and the failure to exclude other indications for CXRs in these patients.

  1. High-reliability quality improvement interventions brought about significant, sustained reduction in the use of chest radiographs (CXR) in children with bronchiolitis and were more effective than educational campaigns.

  2. These interventions helped significantly reduce overuse of CXRs and improve care for children.

Liz Meszaros, Deputy Managing Editor, BreakingMED™

Frazier declared no conflicts of interest.

Cat ID: 138

Topic ID: 85,138,730,138,192,195,925,481,96