335 - An Initiative to Reduce Chest Radiograph Usage in Asthma Exacerbations at a Pediatric Emergency Department
Saturday, April 29, 2023
3:30 PM – 6:00 PM ET
Poster Number: 335 Publication Number: 335.209
Andrew Shieh, University of Michigan, Ann Arbor, MI, United States; Melissa Ann. Brooks, University of Michigan Medical School, Flint, MI, United States
Pediatric Emergency Medicine Fellow Physician University of Michigan Ann Arbor, Michigan, United States
Background: Chest radiographs (CXRs) are not recommended for routine assessment of children with asthma exacerbations and should be reserved when an alternative diagnosis is suspected. However, many pediatric patients will undergo CXRs during evaluation in the emergency department (ED) due to concern for a concomitant community-acquired pneumonia, contributing to unnecessary cost and radiation exposure. Objective: Our aim was to decrease chest radiograph usage for acute asthma exacerbations by 25% by implementing a bedside clinical practice guideline (CPG) at a single tertiary care academic pediatric ED. Design/Methods: We included all children between 2- and 21-years old who presented to our pediatric ED from January 2020 through November 2022 with a primary ICD-10 billing code for asthma. Patients with prior cardiac disease, immunosuppression, tracheostomy, airway anomalies, suspected foreign body ingestion, severe neurologic disorders, sickle cell disease, transferred from another hospital, or intubated in our ED were excluded. Data was obtained from Michigan Emergency Department Improvement Collaborative (MEDIC), an electronic data repository in our state, and the hospital electronic medical record. Data from January 2020 through January 2022 served as 2 years of baseline data prior to CPG implementation. Our CPG (Figure 1) was implemented through posters in our ED work area and educational sessions among resident, fellow, and attending physicians. Results: We included a total of 1,747 ED encounters for asthma, of which 648 (37%) occurred in the post-implementation period. Overall, CXR was ordered in 664 (38%) encounters during the entire study period. Implementation of our asthma CPG was associated with decreased CXR use from 42.2% to 30.8% (Figure 2). A reduction in CXR usage has been sustained for 8 months. Antibiotic use during the pre-implementation period was 4.0%, which decreased to 3.8% during the post-implementation period. The admission rate increased from 277 (25%) encounters during the pre-implementation period to 200 (31%) encounters during the post-implementation period.
Conclusion(s): Implementation of a bedside asthma CPG produced sustained reduction of CXR use by 25% for pediatric patients with acute asthma exacerbations in the ED despite a period of increased admission rate. Antibiotic use decreased slightly with a reduction in CXR usage. Further targeted interventions in addition to implementation of a CPG and bedside educational sessions are likely necessary to decrease CXR usage even further.
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