Resident State University of New York Downstate Medical Center College of Medicine brooklyn, New York, United States
Background: Asthma exacerbation is a common condition for Emergency Department (ED) visits in the pediatric population. In the United States, almost 60% of children with asthma have exacerbations annually and approximately 20% of them need ED visits. Current national guidelines recommend against doing routine chest X-rays (CXR) for patients with acute asthma exacerbations. Baseline data analysis revealed that the percentage of CXRs not meeting the guidelines in children presenting to the ED with asthma exacerbations was 50% at our hospital. Objective: To decrease the percentage of CXRs obtained for pediatric patients presenting to the ED and admitted to the inpatient pediatric unit with acute asthma exacerbation from 50% to 20% in 6 months. Design/Methods: Current guidelines for obtaining a CXR in pediatric patients with asthma exacerbations were reviewed, and CXR indications were identified. The study was conducted by reviewing the Electronic Medical records of patients from 2-21 years with a discharge diagnosis of asthma both from the ED and the inpatient units. The exclusion criteria were intensive care admissions and associated comorbidities. A set of interventions was developed and applied in cycles using the Plan-Do-Study-Act (PDSA) quality improvement methodology. The first intervention was 1:1 provider education; the second intervention was giving each provider a pocket card on the indications for CXR. The third was creating and displaying posters in the ED about the CXR indications, and the fourth intervention was a mass email to the ED physicians and pediatricians. The study was IRB approved. Results: The first intervention PDSA 1 with providers' education yielded a slight decrease in CXR usage to 40%. With the introduction of PDSA 2 by distributing pocket cards, the percentage decreased to 24%. With PDSA 3 as a displayed poster in the ED, we observed a significant decrease to < 20%. At PDSA 4 cycle, we reached a steady state with the CXR usage below 20%. There was no increase in readmissions or length of stay in children who didn’t get a CXR.
Conclusion(s): A series of successfully planned interventions decreased the usage of CXRs in children with asthma exacerbation from 50% to below 20% in an urban safety net hospital.
