Bronchiolitis is one of the primary reasons for pediatric hospitalizations in the U.S., yet wide variation exists in diagnostic protocols. Despite clear American Academy of Pediatrics (AAP) recommendations against obtaining chest x-rays (CXR) for bronchiolitis, overutilization continues.
“In a classic bronchiolitis case, a chest x-ray has no impact, but 42 to 55 percent of providers order them when bronchiolitis is suspected,” said Barron Frazier, M.D., a fellow in pediatric emergency medicine at Monroe Carell Jr. Children’s Hospital at Vanderbilt. Frazier is the lead author of a quality improvement study undertaken at Children’s Hospital from 2012 to 2019 that shows CXR utilization for bronchiolitis encounters can be reduced through an improved clinical workflow.
“Finding areas in which we can safely do less is vital for our patients,” said David Johnson, M.D., medical director of inpatient quality and patient safety at Children’s Hospital. “Working with providers to adhere to the AAP recommendations of diagnosing bronchiolitis without the use of chest radiography is one tangible way to safely do less.”
“Diagnosing bronchiolitis without the use of chest radiography is one tangible way to safely do less.”
The AAP guidelines, last revised in 2014, state that clinicians should diagnose bronchiolitis based on the history of the present illness and physical examination. They recommend imaging “only in severe cases that warrant intensive care or in which there is the possibility of airway complication.”
Often, parts of the lung can be stuck together from inflammation or atelectasis, Frazier explained, which can be interpreted as opacity or pneumonia and can prompt the physician to prescribe antibiotics unnecessarily. “While there are other diagnostic tests available, such as viral testing, these too ultimately do not impact the management of this condition and are not recommended for routine use,” he said.
“There is research that shows there’s no change in patient outcome by not getting an x-ray, but some clinicians worry about missing other diagnoses that perpetuate continued reliance on radiography.”
A First Effort at Changing Habit
Prior to the quality improvement study, Children’s Hospital’s CXR utilization in suspected bronchiolitis cases was 42 percent. Frazier’s team thought they could do better.
In 2013, Greg Plemmons, M.D., associate professor of pediatrics and hospital medicine at Vanderbilt, led a group to develop an evidence-based pediatric bronchiolitis clinical practice guideline to standardize bronchiolitis care. They developed a live dashboard for bronchiolitis encounters using ICD-9 and ICD-10 primary diagnosis codes for children under 2 years of age to monitor data in real-time. A new order set streamlined the recommended steps for bronchiolitis care.
No significant change in CXR utilization was seen following the guideline introduction or the publication of the new 2014 AAP guidelines, Frazier noted.
Implementing Continuous Quality Improvement
“Providers were ordering x-rays for asthma exacerbations directly from a ‘dyspnea’ order set which included a chest x-ray. When the order set was updated in July 2015 removing the chest x-ray choice, we saw a corresponding unintentional decrease in CXR utilization for bronchiolitis from 42 to 23 percent,” Johnson said.
With this understanding, Frazier, Johnson and Plemmons focused on workflow redesign and physician support tools to further discourage CXR overutilization. In 2018, the team issued a specific order set for bronchiolitis and incorporated best practice advisory flags in the EHR that brought CXR utilization down to 18.9 percent. Last fall, they began delivering individual provider feedback on a monthly basis and using statistical process control charts to monitor data.
True quality improvement, Frazier says, is continually updating clinical practice using a systemic, intentional understanding of data to help drive improvement. “If we can save a child from being exposed to radiation and to medications that ultimately are not going to be helpful, that’s meaningful.”
“If we can save a child from being exposed to radiation and to medications that ultimately are not going to be helpful, that’s meaningful.”