Using QI to break bad habits

Abstract

When you take your car to Meineke, chances are you will get a muffler. Well, it seems when you take children to the emergency department or an urgent care center for abdominal pain due to constipation, chances are they will get an abdominal x-ray (AXR). Children discharged with a diagnosis of constipation account for up to 25% of cases seen in some emergency departments or urgent care centers, and as many as 30%-90% will have an AXR as part of their evaluation. Evidenced-based guidelines for the “Evaluation and Treatment of Functional Constipation in Infants and Children” published jointly by the North American and European Societies for Pediatric Gastroenterology, Hepatology and Nutrition, state the diagnosis of functional constipation is based on history and examination and, in the absence of alarm signs and symptoms, routine use of an AXR has no role in the diagnosis. Therefore, it appears many children with functional constipation are being exposed to unnecessary irradiation and the use of AXRs is adding nothing to management but is simply adding to the already high costs of health care in the US. How then can we break some bad habits? One way would be to develop a quality improvement (QI) program aimed at reducing the number of unnecessary AXRs in emergency departments and urgent care clinics. In this volume of The Journal, Moriel et al demonstrate just how effective such a program can be. Using Plan-Do-Study-Act cycles they were able to reduce the use of AXRs for functional constipation from 43% to 21% by emergency department attendings and fellows and from 31% to 16.5% by urgent care clinic pediatricians and pediatric nurses. Together this translated into a reduction of unnecessary AXRs from 36% to 18% with no increase in missed diagnoses or other adverse outcomes. QI activities can be highly effective means of changing practice. Two keys to success in this program were the presence of a “champion” and the provision of individualized data reports to the providers. As physicians we are all somewhat competitive so comparing our individual results to those of our peers can serve as a powerful motivating factor to do better. Hopefully, this report will spur others to design similar projects to decrease unnecessary testing in children seeking health care in the future. Article page 109 ▸ Reducing Abdominal Radiographs to Diagnose Constipation in the Pediatric Emergency DepartmentThe Journal of PediatricsVol. 225PreviewTo determine the frequency of abdominal radiographs obtained in healthy children aged 6 months to 18 years to diagnose constipation in a pediatric emergency department, and evaluate the impact of quality improvement (QI) interventions on their use. Full-Text PDF