189 Chest Radiograph Utilization in Children With Mild-Moderate Asthma: Effect of Clinical Guidelines and Does Emergency Department Volume Matter?

Abstract

Asthma is one of the most common conditions seen in the pediatric population with > 600,000 ED visits/year for acute asthma exacerbations. Studies have demonstrated that chest radiograph (CXR) is the most frequently ordered ancillary test in exacerbations, despite the fact that no recommendations support this. Even in the setting of fever, hypoxia, or crackles, CXR does not change management, and should only be limited to patients who either do not improve after bronchodilator therapy or were started on antibiotics within a week of ED presentation. Children with asthma frequently have some degree of consolidation due to secretions and airway obstruction and this can mistakenly be read as pneumonia, resulting in unnecessary antibiotic usage. Rolling out standardized asthma guidelines has been shown to improve asthma care and decrease CXR utilization. Based off of this information we hypothesized that introduction of standard asthma practice guidelines throughout our multi-center hospital system would decrease CXR utilization in the ED. Study data was abstracted from November 2015 to November 2017 from the electronic medical record (EMR) for patients aged 0-18 seen in 12 EDs both pediatric-specific and general EDs (adults and children) with an ED discharge diagnosis of mild to moderate asthma defined as a primary discharge diagnosis of asthma or wheeze discharged from the ED (mild to moderate asthma). The following variables were extracted: age groups <1 yr., 1-4 yrs., 5-9 yrs. 10-14 yrs., 15-17 yrs. and >17, sex, and receipt of a CXR in the pediatric-specific and general EDs were stratified by pediatric volume low 1-1799, medium 1800-4999, medium-high 5000-9999, high >10,000. Descriptive statistics were used to assess differences in CXR utilization prior to and after the publication of a standardized asthma guideline (November 2016). There were 4398 mild-to-moderate asthma visits included from 8 hospitals (after exclusion of 4 hospitals with a total of 418 visits that we did not have pre-data). The CXR performance per age groups: <1 yr. (29.8%), 1-4 yrs. (27.4%), 5-9 yrs. (23.8%), 10-14 yrs. (22.9%), 15-17 yrs. (32.8%) and >17 (39.9%); 59% males; 75% not Hispanic or Latino. The CXR performance pre- and post-guidelines was as follows: 1 pediatric-specific ED 21.8% versus 20.96%; 1 high volume ED 41% versus 42.9%; 2 medium-high volume ED 32.7% versus 31.74%; 3 medium volume ED 36.8 % versus 37.69%; and 1 low volume ED 38.2% versus 36.84%. Judicious use of CXR is noted to limit radiation and incidental findings, improve patient safety, and reduce costs. The pediatric-specific ED performed a significantly lower percentage of CXR in mild to moderate asthma patients discharged from the ED as compared to general EDs. Implementation of a system wide asthma policy did not show a significant decrease in CXR utilization across all EDs. Further education of clinicians and embedding asthma guidelines in a standard workflow are necessary to continue to decrease unnecessary CXR usage.