Quality Improvement Project to Reduce Unnecessary Chest X-Rays in Children with Asthma Exacerbations

From the 2021 HVPAA National Conference

Mohamed Sakr (Brookdale Hospital Medical Center), Mohamed Alkanjo, Palanikumar Balasundaram, Ameet Kumar, Hyunbin Park, Fernanda Kupferman, Ratna Basak

Background

Asthma exacerbation are a common reason for Emergency Department (ED) visits in the pediatric population. In the United States, 60% of asthmatic children have one or more acute exacerbations each year, and approximately 20% of them require ED visits annually. Current national guidelines recommend against doing routine chest x ray (CXR) for patients with acute asthma exacerbations.

Objective

To decrease the number of unnecessary chest x rays for pediatric patients aged 2-18 years presenting with acute asthma exacerbations in order to reduce radiation exposure, ED stay, use of antibiotics and cost. Our aim is to decrease the percentage of unnecessary chest x rays by 50% of pre-intervention level in 6 months.

Methods

Using Plan-Do-Study-Act (PDSA) quality improvement methodology, a team of pediatrics and ED providers was assembled to identify ways to improve compliance with the current guidelines to limit unnecessary chest x rays for pediatric patients with acute asthma exacerbations. Charts of pediatric patients between 2 and 18 years of age, who presented to ED with asthma exacerbations were reviewed to establish the pre-intervention percentage of chest x rays performed with no indications as per the guidelines. These guidelines are summarized in Table 1.

The team prepared an educational program (intervention) for post assessment application. The interventions were one-to-one education of ED providers about CXR indications in asthma exacerbations, setting posters in ED about the indications, providing ED providers with printed cards of CXR indications, an interactive educational grand round about the project for pediatrics and ED providers, and finally implementing EPIC drop-down reminder list for CXR order.

Results

Baseline data review revealed that the pre-intervention percentage of unnecessary CXR, in children presented to ED with asthma exacerbations and had CXRs performed, was ranging from 36-44% (Figure. 1) (112 children presented to ED with asthma exacerbations in the 3 months prior to the educational program; 57 (51%) had CXRs, of which 21 (37%) were unnecessary). We implemented the first step of program (one-to-one education); subsequently, during the 3-week period following the education program, 44 cases presented to ED with asthma exacerbations; 20 had CXRs (45%), of which 5 (25%) were unnecessary.

Subsequent data analysis showed further reduction in CXRs in our targeted population to 23%, after setting posters in ED about the indications (April 2019). Providing ED providers with printed cards of CXR indications (May 2019), lead to further reduction down to 19%. Our fourth intervention was presenting an interactive educational grand round about the project for pediatrics and ED providers (Sep 2019), after which the percentage dropped down to 15%, which was below our target bench mark (18%). Finally, implementing EPIC drop-down reminder list for CXR order (Oct 2019) lead to further reduction in unnecessary CXRs in our population down to 12%.

Conclusion

Implementing the previous mentioned interventions has safely reduced unnecessary CXRs in children with asthma exacerbations. Our high-yield interventions were at essentially no monetary cost and low time cost to team members to plan, test, and analyze changes and could theoretically be efficiently and easily incorporated . With our interventions, we set a framework for improvement that could be expanded for other purposes or disease processes as well.

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