A quality improvement intervention to reduce emergency department radiography for bronchiolitis

Systematic review of interventions aimed at improving the quality of referrals to radiology

Despite ubiquitous use of medical imaging in daily medical practice, the quality of referrals varies significantly across a variety of practice types and locations. This systematic review summarises studies in the literature that have employed interventions aimed at improving radiology referrals, excluding clinical decision support software. A systematic review of literature was conducted in PubMed, EMBASE, Scopus, and Cochrane. Two reviewers independently identified studies for inclusion. All studies that included interventions with any outcome measure were included. Any irrelevant studies, non-English studies or not retrievable studies were excluded. Studies were grouped into Education, Feedback, Rationing, Penalties, and Other. The outcomes of the studies were summarised and qualitatively analysed due to anticipated heterogeneity. Four thousand six hundred and forty-two studies were identified throughout PubMed, EMBASE, Scopus, and Cochrane. One hundred and eighty-seven duplicates were removed and 4436 abstracts were screened. Two hundred and forty were identified on the first phase of the screening with 167 then excluded for non-relevancy. Seventy-five full studies were included in the final analysis following the addition of 2 additional studies. Fifty-seven studies were grouped into Education, 10 into Feedback, 4 into Rationing, 8 into Penalties, 9 into Other and 11 containing multiple. Eighty-four percent of the studies reported an improvement in the quality of the referrals. Despite a variable rate of quality referrals, there are many interventions that radiology departments across the world can utilise to improve the referral process.

Local healthcare professionals need to work together to implement bronchiolitis guidelines that stop unnecessary tests and treatments

AIM

This mini review summarised studies published over a 10-year period on the impact of guidelines for diagnosing and managing bronchiolitis in children, with a special focus on interventions that enhanced adherence during implementation.

METHODS

PubMed was searched from 1 December 2011 to 31 November 2021 for papers published in English that used the terms bronchiolitis, child or infant, guidelines and either implementation or impact. After the exclusion criteria had been applied, 27 articles were reviewed in more detail. Eight described protocols without any comparisons and were excluded. Ten of the 19 remaining studies evaluated the impact of bronchiolitis guidelines, and 9 examined the effects of interventions linked to their publication.

RESULTS

Just releasing evidence-based guidelines had a poor impact, but this improved when local tailored current care, clinical practice or best-practice guidelines were issued. Even better results were achieved when all the staff treating bronchiolitis patients participated in the preparation and implementation of local guidelines. Adherence to the guidelines was as high as 85% when multidisciplinary, and multifaceted interventions were used to complement the publication of guidelines.

CONCLUSION

Healthcare professionals need to work together to avoid children receiving bronchiolitis management that is unnecessary and not based on evidence.

Reducing thoracic and lumbar radiographs in an urban emergency department through a clinical champion led quality improvement intervention

Background

Low back pain is a common emergency department (ED) complaint that does not always necessitate imaging. Unnecessary imaging drives medical overuse with potential to harm patients. Quality improvement (QI) interventions have shown to be an effective solution. The purpose of this QI intervention was to increase the percentage of appropriately ordered radiographs for low back pain while reducing the absolute number.

Methods

A multi-component intervention led by a clinician champion including staff education, patient education, electronic medical record modification, audit and peer-feedback, and clinical decision support tools was implemented at an urban public hospital Emergency Department. In addition to the total number ordered, Choosing Wisely and American College of Radiology recommendations were used to assess appropriateness of all ED thoracic and lumbar conventional radiographs by chart review over eight months.

Results

The percent of appropriately ordered radiographs increased from 5.8 to 53.9% and the monthly number of radiographs ordered decreased from 86 to 47 over the eight-month initiative. There were no compensatory increases in thoracic or lumbar computed tomography (CT) scans during this time frame.

Conclusion

A multi-component QI intervention led by a clinician champion is an effective way to reduce the overutilization of thoracic and lumbar radiographs in an urban public hospital emergency department.

Interventions to reduce low-value imaging - a systematic review of interventions and outcomes

BACKGROUND

It is estimated that 20-50% of all radiological examinations are of low value. Many attempts have been made to reduce the use of low-value imaging. However, the comparative effectiveness of interventions to reduce low-value imaging is unclear. Thus, the objective of this systematic review was to provide an overview and evaluate the outcomes of interventions aimed at reducing low-value imaging.

METHODS

An electronic database search was completed in Medline - Ovid, Embase-Ovid, Scopus, and Cochrane Library for citations between 2010 and 2020. The search was built from medical subject headings for Diagnostic imaging/Radiology, Health service misuse or medical overuse, and Health planning. Keywords were used for the concept of reduction and avoidance. Reference lists of included articles were also hand-searched for relevant citations. Only articles written in English, German, Danish, Norwegian, Dutch, and Swedish were included. The Mixed Methods Appraisal Tool was used to appraise the quality of the included articles. A narrative synthesis of the final included articles was completed.

RESULTS

The search identified 15,659 records. After abstract and full-text screening, 95 studies of varying quality were included in the final analysis, containing 45 studies found through hand-searching techniques. Both controlled and uncontrolled before-and-after studies, time series, chart reviews, and cohort studies were included. Most interventions were aimed at referring physicians. Clinical practice guidelines (n = 28) and education (n = 28) were most commonly evaluated interventions, either alone or in combination with other components. Multi-component interventions were often more effective than single-component interventions showing a reduction in the use of low-value imaging in 94 and 74% of the studies, respectively. The most addressed types of imaging were musculoskeletal (n = 26), neurological (n = 23) and vascular (n = 16) imaging. Seventy-seven studies reported reduced low-value imaging, while 3 studies reported an increase.

CONCLUSIONS

Multi-component interventions that include education were often more effective than single-component interventions. The contextual and cultural factors in the health care systems seem to be vital for successful reduction of low-value imaging. Further research should focus on assessing the impact of the context in interventions reducing low-value imaging and how interventions can be adapted to different contexts.

Impact on radiological practice of active guideline implementation of musculoskeletal guideline, as measured over a 12-month period

Background

An ever-increasing technological development in the field of radiology urges a need for guidelines to provide predictable and just health services. A musculoskeletal guideline was developed in Norway in 2014, without active implementation.

Purpose

To investigate the impact of active guideline implementation on the use of musculoskeletal diagnostic imaging most frequently encountered in general practice (pain in the neck, shoulders, lower back, and knees).

Material and Methods

The total number of outpatient radiological examinations across modalities registered at the Norwegian Health Economics Administration between January 2013 and February 2019 was assessed using an interrupted time series design.

Results

A 12% reduction in the total examination of Magnetic Resonance Imaging shoulder and knee, and x-ray lower back and shoulder was found at a significant level (p = 0.05). Stratified analysis (Magnetic Resonance Imaging examination as one group and x-ray examinations as the other) showed that this reduction mainly was due to the reduction in the use of Magnetic Resonance Imaging examinations (shoulder and knee) which was reduced by 24% at a significant level (p = 0.002), while x-ray examinations had no significant level change (p = 0.71). No other statistically significant changes were found.

Conclusion

The impact of the implementation on the use of imaging of the neck, shoulder, lower back, and knee is uncertain. Significant reductions were demonstrated in the use of some examinations in the intervention county, but similar effects were not seen when including a control group in the analysis. This indicates a diffusion of the implementation, or other interventions or events that affected both counties and occurred in the intervention period.

EXPOSURE OF PEDIATRIC EMERGENCY PATIENTS TO IMAGING EXAMS, NOWADAYS AND IN TIMES OF COVID-19: AN INTEGRATIVE REVIEW

Objective:

To analyze literature data about unnecessary exposure of pediatric emergency patients to ionizing agents from imaging examinations, nowadays and during times of COVID-19.

Data sources:

Between April and July 2020, articles were selected using the databases: Virtual Health Library, PubMed and Scientific Electronic Library Online. The following descriptors were used: [(pediatrics) AND (emergencies) AND (diagnostic imaging) AND (medical overuse)] and [(Coronavirus infections) OR (COVID-19) AND (pediatrics) AND (emergencies) AND (diagnostic imaging)]. Inclusion criteria were articles available in full, in Portuguese or English, published from 2016 to 2020 or from 2019 to 2020, and articles that covered the theme. Articles without adherence to the theme and duplicate texts in the databases were excluded.

Data synthesis:

61 publications were identified, of which 17 were comprised in this review. Some imaging tests used in pediatric emergency departments increase the possibility of developing future malignancies in patients, since they emit ionizing radiation. There are clinical decision instruments that allow reducing unnecessary exam requests, avoiding over-medicalization, and hospital expenses. Moreover, with the COVID-19 pandemic, there was a growing concern about the overuse of imaging exams in the pediatric population, which highlights the problems pointed out by this review.

Conclusions:

It is necessary to improve hospital staff training, use clinical decision instruments and develop guidelines to reduce the number of exams required, allowing hospital cost savings; and reducing children’s exposure to ionizing agents.

Group-facilitated audit and feedback to improve bronchiolitis care in the emergency department

Objective

Despite strong evidence recommending supportive care as the mainstay of management for most infants with bronchiolitis, prior studies show that patients still receive low-value care (e.g., respiratory viral testing, salbutamol, chest radiography). Our objective was to decrease low-value care by delivering individual physician reports, in addition to group-facilitated feedback sessions to pediatric emergency physicians.

Methods

Our cohort included 3,883 patients ≤ 12 months old who presented to pediatric emergency departments in Calgary, Alberta, with a diagnosis of bronchiolitis from April 1, 2013, to April 30, 2018. Using administrative data, we captured baseline characteristics and therapeutic interventions. Consenting pediatric emergency physicians received two audit and feedback reports, which included their individual data and peer comparators. A multidisciplinary group-facilitated feedback session presented data and identified barriers and enablers of reducing low-value care. The primary outcome was the proportion of patients who received any low-value intervention and was analysed using statistical process control charts.

Results

Seventy-eight percent of emergency physicians consented to receive their audit and feedback reports. Patient characteristics were similar in the baseline and intervention period. Following the baseline physician reports and the group feedback session, low-value care decreased from 42.6% to 27.1% (absolute difference: −15.5%; 95% CI: −19.8% to −11.2%) and 78.9% to 64.4% (absolute difference: −14.5%; 95% CI: −21.9% to −7.2%) in patients who were not admitted and admitted, respectively. Balancing measures, such as intensive care unit admission and emergency department revisit, were unchanged.

Conclusion

The combination of audit and feedback and a group-facilitated feedback session reduced low-value care for patients with bronchiolitis.

[Predictive factors for failure of continuous positive airway pressure treatment in infants with bronchiolitis]

OBJECTIVE

To study the predictive factors for the failure of continuous positive airway pressure (CPAP) treatment in infants with bronchiolitis.

METHODS

A retrospective analysis was performed on the clinical data of 310 hospitalized children (aged 1-12 months) with bronchiolitis treated with CPAP. Their clinical features were compared between the successful treatment group (270 cases) and the failed treatment group (40 cases). A multivariate logistic regression analysis was used to explore the predictive factors for failure of CPAP treatment.

RESULTS

The multivariate logistic regression analysis showed that the score of the Pediatric Risk of Mortality III (PRISM III) ≥10 (OR=13.905), development of atelectasis (OR=12.080), comorbidity of cardiac insufficiency (OR=7.741), and no improvement in oxygenation index (arterial partial pressure of oxygen/fraction of inhaled oxygen, P/F) after 2 hours of CPAP treatment (OR=34.084) were predictive factors for failure of CPAP treatment for bronchiolitis (P<0.05). In predicting CPAP treatment failure, no improvement in P/F after 2 hours of CPAP treatment had an area under the receiver operating characteristic curve of 0.793, with a sensitivity of 70.3% and a specificity of 82.4% at a cut-off value of 203.

CONCLUSIONS

No improvement in P/F after 2 hours of CPAP treatment, PRISM III score ≥10, development of atelectasis, and comorbidity of cardiac insufficiency can be used as predictive factors for CPAP treatment failure in infants with bronchiolitis.

Actively Doing Less: Deimplementation of Unnecessary Interventions in Bronchiolitis Care Across Urgent Care, Emergency Department, and Inpatient Settings

BACKGROUND AND OBJECTIVES

Quality improvement (QI) initiatives have increased provider adherence to individual components of a bronchiolitis clinical practice guideline (CPG). Few have evaluated complete adherence to a guideline in multiple types of care settings. Our aim with this study was to increase complete adherence to our institutional bronchiolitis CPG in urgent care center, emergency department, and inpatient settings.

METHODS

We conducted a QI study at a single pediatric institution with multiple care settings. Encounters for patients with bronchiolitis ages >60 days to <24 months occurring between October 1 and March 31 in 2015-2018 were included. Those in intensive or subspecialty care were excluded. Management of each encounter was considered adherent to the CPG if none of the following were ordered: respiratory pathogen panel, respiratory syncytial virus antigen, complete blood cell count, blood culture, chest radiography, bronchodilator, antibiotic, or systemic corticosteroid. Medical team education, family engagement, order set modifications, and data dissemination were employed to drive deimplementation. We used interrupted time series to assess changes in processes and outcomes both across and within seasons.

RESULTS

Analysis included 13 063 patient encounters. Hospital-wide complete adherence to the CPG increased (P < .001) from 40.9% (95% confidence interval 39.3%-42.5%) to 54.6% (95% confidence interval 53.2%-56.0%). Although CPG adherence improved in all 3 clinical settings, the use of individual CPG components varied by setting. Direct cost decreased in the urgent care center (P < .001) and emergency department (P = .001).

CONCLUSIONS

We created a strict definition of CPG adherence and used QI methodology to deimplement multiple overused tests and medications across the continuum of patient care.