CXR Use Research Articles

Preferences for Management of Pediatric Pneumonia: A Clinician Survey of Artificially Generated Patient Cases.

It is unknown which factors are associated with chest radiograph (CXR) and antibiotic use for suspected community-acquired pneumonia (CAP) in children. We evaluated factors associated with CXR and antibiotic preferences among clinicians for children with suspected CAP using case scenarios generated through artificial intelligence (AI). We performed a survey of general pediatric, pediatric emergency medicine, and emergency medicine attending physicians employed by a private physician contractor. Respondents were given 5 unique, AI-generated case scenarios. We used generalized estimating equations to identify factors associated with CXR and antibiotic use. We evaluated the cluster-weighted correlation between clinician suspicion and clinical prediction model risk estimates for CAP using 2 predictive models. A total of 172 respondents provided responses to 839 scenarios. Factors associated with CXR acquisition (OR, [95% CI]) included presence of crackles (4.17 [2.19, 7.95]), prior pneumonia (2.38 [1.32, 4.20]), chest pain (1.90 [1.18, 3.05]) and fever (1.82 [1.32, 2.52]). The decision to use antibiotics before knowledge of CXR results included past hospitalization for pneumonia (4.24 [1.88, 9.57]), focal decreased breath sounds (3.86 [1.98, 7.52]), and crackles (3.45 [2.15, 5.53]). After revealing CXR results to clinicians, these results were the sole predictor associated with antibiotic decision-making. Suspicion for CAP correlated with one of 2 prediction models for CAP (Spearman's rho = 0.25). Factors associated with a greater suspicion of pneumonia included prior pneumonia, duration of illness, worsening course of illness, shortness of breath, vomiting, decreased oral intake or urinary output, respiratory distress, head nodding, focal decreased breath sounds, focal rhonchi, fever, and crackles, and lower pulse oximetry. Ordering preferences for CXRs demonstrated similarities and differences with evidence-based risk models for CAP. Clinicians relied heavily on CXR findings to guide antibiotic ordering. These findings can be used within decision support systems to promote evidence-based management practices for pediatric CAP.

Point-of-care ultrasound as a diagnostic tool in respiratory assessment in awake paediatric patients: a comparative study

BackgroundChest X-ray (CXR) has typically been the main investigation in children with suspected respiratory pathology. Recent advances in lung point-of-care ultrasound (POCUS) have shown the potential for it to be...

Chest X-ray Overuse in Cardiothoracic Intensive Care Unit per American College of Radiology Criteria

BackgroundA routine chest radiograph (CXR) is frequently incorporated into postoperative clinical pathways. Whereas prior studies evaluated CXR use for specific indications, overall CXR "stewardship" within cardiothoracic surgery remains undescribed. We characterized CXR use within a cardiothoracic intensive care unit (ICU) and quantified X-ray–driven changes in patient management. MethodsAll CXRs performed during 3 months in the cardiothoracic ICU of an academic 900-bed tertiary care hospital were retrospectively reviewed. Attending radiologist CXR reports and clinical history from ordering providers were manually reviewed to classify CXRs as indicated or not indicated by American College of Radiology (ACR) Appropriateness Criteria. Multiple resident-level providers further reviewed CXRs to determine whether the image demonstrated any actionable or unexpected findings. ResultsBetween October 1, 2021, and January 3, 2022, 1273 CXRs were performed on adult cardiac and general thoracic surgery patients; the most common indication was routine daily (55.9%), followed by support device monitoring (12.4%) and new ICU transfer (10.4%). Only 34.3% of performed CXRs met ACR Appropriateness Criteria; 65.7% did not (P = .002). Only 3.8% of not indicated CXRs had actionable or significant findings vs 13.0% of indicated CXRs (P = .02). Of the 32 not indicated CXRs with actionable findings, 37.5% recommended endotracheal tube repositioning and 28.1% recommended other line or tube repositioning. ConclusionsCXRs are overused in the cardiothoracic ICU according to ACR Appropriateness Criteria. CXRs performed outside these guidelines have significantly fewer actionable or meaningful findings. Optimizing CXR use can improve resource utilization and efficiency in care of cardiothoracic surgical patients.

A Prediction Model for Pediatric Radiographic Pneumonia.

Chest radiographs (CXRs) are frequently used in the diagnosis of community-acquired pneumonia (CAP). We sought to construct a predictive model for radiographic CAP based on clinical features to decrease CXR use. We performed a single-center prospective study of patients 3 months to 18 years of age with signs of lower respiratory infection who received a CXR for suspicion of CAP. We used penalized multivariable logistic regression to develop a full model and bootstrapped backward selection models to develop a parsimonious reduced model. We evaluated model performance at different thresholds of predicted risk. Radiographic CAP was identified in 253 (22.2%) of 1142 patients. In multivariable analysis, increasing age, prolonged fever duration, tachypnea, and focal decreased breath sounds were positively associated with CAP. Rhinorrhea and wheezing were negatively associated with CAP. The bootstrapped reduced model retained 3 variables: age, fever duration, and decreased breath sounds. The area under the receiver operating characteristic for the reduced model was 0.80 (95% confidence interval: 0.77-0.84). Of 229 children with a predicted risk of <4%, 13 (5.7%) had radiographic CAP (sensitivity of 94.9% at a 4% risk threshold). Conversely, of 229 children with a predicted risk of >39%, 140 (61.1%) had CAP (specificity of 90% at a 39% risk threshold). A predictive model including age, fever duration, and decreased breath sounds has excellent discrimination for radiographic CAP. After external validation, this model may facilitate decisions around CXR or antibiotic use in CAP.

Reducing Chest Radiographs in Bronchiolitis Through High-Reliability Interventions

Bronchiolitis is a leading cause of pediatric hospitalization in the United States, resulting in significant morbidity and health care resource use. Despite American Academy of Pediatrics recommendations against obtaining chest radiographs (CXRs) for bronchiolitis, variation in care continues. Historically, clinical practice guidelines and educational campaigns have had mixed success in reducing unnecessary CXR use. Our aim was to reduce CXR use for children <2 years with a primary diagnosis of bronchiolitis, regardless of emergency department (ED) disposition or preexisting conditions, from 42.1% to <15% of encounters by March 2020. A multidisciplinary team was created at our institution in 2012 to standardize bronchiolitis care. Given success with higher reliability interventions in asthma, similar interventions affecting workflow were subsequently pursued with bronchiolitis, starting in 2017, by using quality improvement science methods. The primary outcome was the percent of bronchiolitis encounters with a CXR. The balancing measure was return visits within 72 hours to the ED. Statistical process control charts were used to monitor and analyze data obtained from an internally created dashboard. From 2012 to 2020, our hospital had 12 120 bronchiolitis encounters. Preimplementation baseline revealed a mean of 42.1% for CXR use. Low reliability interventions, like educational campaigns, resulted in unsustained effects on CXR use. Higher reliability interventions were associated with sustained reductions to 23.3% and 18.9% over the last 4 years. There was no change in ED return visits. High-reliability workflow redesign was more effective in translating American Academy of Pediatrics recommendations into sustained practice than educational campaigns.

Development of a Health Disparities Index: Proof of Concept with Chest Radiography in Asthma

To develop a tool for quantifying health disparity (Health Disparity Index[HDI]) and explore hospital variation measured by this index using chest radiography (CXR) in asthma as the proof of concept. This was a retrospective cohort study using the Pediatric Health Information System database including children with asthma between 5 and 18years old. Inpatient and emergency department (ED) encounters from January 1, 2017, to December 31, 2018, with low or moderate severity were included. Exclusions included hospitals with <10 cases in any racial/ethnic group. The HDI measured variation in CXR use among children with asthma based on race/ethnicity. The HDI was calculated as the absolute difference between maximum and minimum percentages of CXR use (range=0-100) when there was statistical evidence that the percentages were different. Data from 36 hospitals included 16 744 inpatient and 75 805 ED encounters. Overall, 19.7% of encounters had a CXR (34.3% for inpatient; 16.5% for ED). In inpatient encounters, 47.2% (17/36) of hospitals had a significant difference in imaging across racial/ethnic groups. Of these, the median hospital-level HDI was 19.4% (IQR 13.5-20.1). In ED encounters, 78.8% (28/36) of hospitals had a statistically significant difference in imaging across racial/ethnic groups, with a median hospital-level HDI of 10.2% (IQR 8.3-14.1). There was no significant association between the inpatient HDI and ED HDI (P=.46). The HDI provides a practical measure of disparity. To improve equity in healthcare, metrics are needed that are intuitive, accurate, usable, and actionable. Next steps include application of this index to other conditions.

Reducing Unnecessary Chest X-Ray Films After Thoracic Surgery: A Quality Improvement Initiative

Previous work has identified that inpatient post-thoracic surgery chest x-ray films (CXR) are overutilized. A three-phase rapid cycle quality improvement initiative was performed to reduce empiric post-thoracic surgery CXR use by 25% over 1 year. We adapted evidence-based guidelines and implemented "plan-do-study-act" (PDSA) cycle methodology. The PDSA cycles included (1) education with literature and preintervention statistics; (2) electronic medical record order-set modification; and (3) audit and feedback with monthly status reports. Each cycle lasted 3 months. Use of CXR was tracked in the post-anesthesia care unit and as a daily rate of non-post-anesthesia care unit CXRs. Cost data were estimated from Centers for Medicare & Medicaid Services fees. During the initiative, 292 thoracic surgery inpatients were monitored. Before intervention, 99% of patients (69 of 70) received a post-anesthesia care unit CXR, and the daily rate of other CXRs was 1.6. Overall, there was a significant reduction in CXR utilization (P< .001). Post-anesthesia care unit CXRs decreased by 42%, lowering to 89% (68 of 76) to 68% (50 of 74) to 57% (41 of 72) in PDSA cycles 1 through 3, respectively. The daily rate of other CXRs decreased by 38%, lowering to 1.4 to 1.3 to 1.0. Patient perioperative characteristics and health care quality measures were not different between cycles. After quality improvement implementation, cost savings were estimated to be at least $73,292 per year. Implementation of our quality improvement initiative safely and systematically reduced empiric CXR use after inpatient thoracic surgery. Results will be used in future quality improvement initiatives to reduce unnecessary postoperative testing.

Trends in Chest Radiographs for Pneumonia in Emergency Departments.

National guidelines recommend against routine use of chest radiography (CXR) for community-acquired pneumonia (CAP) diagnosis in the pediatric emergency department (ED). Given that CXR is often used to exclude the diagnosis of CAP, a reduction in CXR use may result in overdiagnosis of CAP. We sought to evaluate trends in CXR use and assess the association between CXR performance and CAP diagnosis among children discharged from pediatric EDs. Children 3 months to 18 years of age discharged from 30 US EDs with (1) CAP or (2) fever or respiratory illness between 2008 and 2018 were included. Temporal trends in CXR use and rates of CAP diagnoses among patients with fever or respiratory illness were assessed. Correlation between hospital-level CXR use and CAP diagnosis rates were evaluated by using Spearman's correlation weighted by hospital volume. CXR usage decreased from 86.6% to 80.4% (P < .001) for patients with CAP and from 30.4% to 18.6% (P < .001) for children with fever or respiratory illness over the 10-year study period. CAP diagnosis rates also declined from 7.8% to 5.9% (P < .001). Hospital-level CXR use was correlated with pneumonia diagnosis rates (correlation coefficient 0.58; P < .001). Over the past decade, there has been a decline in CXR use in the ED among children with pneumonia and respiratory illnesses, with a decrease in pneumonia diagnoses over the same time period. Future studies are needed to assess the role of CXR in the evaluation of children with possible pneumonia in the ED setting.

Sticking by an Imperfect Standard: Chest Radiography for Pediatric Community-Acquired Pneumonia.

* Abbreviations: CAP — : community-acquired pneumonia CXR — : chest radiography ED — : emergency department PCV13 — : 13-valent pneumococcal conjugate vaccine PHIS — : Pediatric Health Information System PIDS/IDSA — : Pediatric Infectious Diseases Society and Infectious Diseases Society of America For decades, chest radiography (CXR) was considered to be the reference standard for diagnosis of community-acquired pneumonia (CAP). Studies of CAP diagnostics in children have used CXR as both a reference standard and an index test, with disagreement over how and when it should be used.1 Although frequently obtained, CXR has low sensitivity and only fair interrater reliability in diagnosing CAP.2 Radiography cannot differentiate bacterial from viral CAP and does not have substantial impact on outcomes.3 Furthermore, access to CXR is limited in many settings. Given these limitations, the 2011 Pediatric Infectious Diseases Society and Infectious Diseases Society of America (PIDS/IDSA) pediatric CAP guideline recommends against routine CXR to confirm suspected CAP in children managed in the outpatient setting, a strong recommendation citing high-quality evidence.4 Despite this, among children 1 to 6 years of age managed as outpatients in the United States from 2008 to 2015, 83% of children with CAP received CXR in the emergency department (ED) compared with 22% in the primary care setting, with no change after guideline publication.5 This suggests that there is still room to improve, especially in the ED. In this issue of Pediatrics , Geanacopoulos et al6 used the Pediatric Health Information System (PHIS), an administrative database, to evaluate CXR use in 30 pediatric EDs from 2008 to 2018 … Address correspondence to Todd A. Florin, MD, MSCE, Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago Ave, Box 62, Chicago, IL 60611. E-mail: taflorin{at}luriechildrens.org

Successful Chest Radiograph Reduction by Using Quality Improvement Methodology for Children With Asthma

To measure the effect of implementing quality improvement (QI) methodology on the rate of chest radiograph (CXR) ordering for pediatric patients with acute asthma exacerbations.A total of 6680 pediatric patients age ≥2 years seen in the emergency department (ED) of a tertiary care children’s hospital for acute asthma were included in the study.Children ≥2 years old were retrospectively identified by chart review from May 2013 to April 2017. Included subjects had a primary International Classification of Diseases, Ninth Revision or 10th Revision billing code for asthma. An asthma clinical practice guideline (CPG) for CXR ordering in the ED was implemented in May 2014. Thus, the data from May 2013 to April 2014 were included as a 1-year baseline before intervention. Additional QI methods included removal of CXR as a default component of the electronic medical record asthma order set (July 2015), public reminder placement (January 2016), and targeted resident education (February 2016). The primary measure was CXRs ordered as a percentage of total acute asthma encounters, with a preintervention goal of <20%.A total of 1539 CXRs were ordered during 6680 patient encounters. Hospital-wide implementation of an asthma CPG was associated with a decrease in CXR use in acute asthma visits, from 29.3% to 23.0%. Implementation of targeted QI measures was associated with a further reduction in CXR use to 16.0%, which was sustained for 14 months (from February 2016 to April 2017). CXR use decreased from 21.3% to 12.5% in the subset of patients discharged from the hospital from the ED and from 53.5% to 31.1% among patients ultimately admitted to the hospital.Investigators in this study describe sustained reduction in CXR ordering in pediatric patients with acute asthma exacerbations after implementation of a CPG, later followed by QI interventions targeted at the electronic medical record system and at provider education.Old habits die hard. Previous studies have established that routine use of CXR in the evaluation of children with acute asthma exacerbations, the most frequent cause of childhood hospitalization in the United States, is of low diagnostic yield and is associated with significant risk, including unnecessary antibiotic administration. Despite evidence demonstrating low utility of CXR in this setting, implementation of “best” practice into clinical routine is challenging and can take years before change occurs. This study demonstrates how QI methodology can help break old habits, improve clinical care through patient-centered outcome measures, and most importantly, assist clinicians working in busy medical settings. It is impossible for any of us to stay current with the rapidly evolving world of medical knowledge. That is why dedicated use of QI methodology and commitment to changing culture can be so valuable.

Reduction in Unintended Extubations in a Level IV Neonatal Intensive Care Unit.

Unintended extubations (UEs) lead to significant morbidity in neonates. A quality improvement project was initiated in response to high rates in our level IV NICU. We targeted creating and sustaining UE rates below the published standard of 1 per 100 ventilator days. This project spanned 4 time periods: baseline, epoch 1 (December 2010-May 2012), sustain, and epoch 2 (May 2015-December 2017) by using standard quality improvement methodology. Epoch 1 interventions included real-time analysis of UE events, standardization of taping, patient positioning and movement, accurate event reporting, and change in nomenclature. Epoch 2 interventions included reduction in daily chest radiographs (CXRs) and development of a high-risk tool. Patient and event characteristics were statistically compared across time points. Of the 612 UE events recorded over 10 years, 249 UEs occurred from May 2011 to 2017 involving 184 unique patients. UE rates decreased by 43% (from 1.75 to 0.99 per 100 ventilator days; epoch 1) and were sustained until a notable spike. Epoch 2 interventions led to a further 31% rate reduction. Single CXR use decreased by half. Median corrected gestational age at the time of an event was 35 weeks (interquartile range: 29-41). Seventy percent of infants experiencing an UE required reintubation, 29% had a previous event, and 9% had a code event. A decrease in UE below benchmarks can be achieved and sustained by standardization and mitigation interventions. This decline was also accompanied by a reduction in use of CXRs without increasing UE events.

Guideline Adherence in Diagnostic Testing and Treatment of Community-Acquired Pneumonia in Children.

The objective of this study was to determine emergency department (ED) physician adherence with the 2011 Pediatric Infectious Diseases Society (PIDS) and Infectious Diseases Society of America (IDSA) guidelines for outpatient management of children with mild-to-moderate community-acquired pneumonia (CAP). A cross-sectional survey of physicians on the American Academy of Pediatrics Section on Emergency Medicine Survey listserv was conducted. We evaluated ED physicians' reported adherence with the PIDS/IDSA guidelines through presentation of 4 clinical vignettes representing mild-to-moderate CAP of presumed viral (preschool-aged child), bacterial (preschool and school-aged child), and atypical bacterial (school-aged child) etiology. Of 120 respondents with analyzable data (31.4% response rate), use of chest radiograph (CXR) was nonadherent to the guidelines in greater than 50% of respondents for each of the 4 vignettes. Pediatric emergency medicine fellowship training was independently associated with increased CXR use in all vignettes, except for school-aged children with bacterial CAP. Guideline-recommended amoxicillin was selected to treat bacterial CAP by 91.7% of the respondents for preschool-aged children and by 75.8% for school-aged children. Macrolide monotherapy for atypical CAP was appropriately selected by 88.2% and was associated with obtaining a CXR (adjusted odds ratio, 3.9 [95% confidence interval, 1.4-11.1]). Guideline-adherent antibiotic use for all vignettes was independently associated with congruence between respondent's presumed diagnosis and the vignette's intended etiologic diagnosis. Reported ED CXR use in the management of outpatient CAP was often nonadherent to the PIDS/IDSA guidelines. Most respondents were adherent to the guidelines in their use of antibiotics. Strategies to increase diagnostic test accuracy are needed to improve adherence and reduce variation in care.

Provision of Guideline-Based Pediatric Asthma Care in US Emergency Departments.

National guidelines for routine pediatric acute asthma care recommend providing corticosteroids, and discourage routinely obtaining chest radiographs (CXRs) and using antibiotics. We examined rates of adherence to all 3 of these aspects during emergency department (ED) visits and compared performance between pediatric and general EDs. Using the National Hospital Ambulatory Medical Care Survey, we included all nontransfer ED visits for patients younger than 19 years with a diagnosis of asthma and treatment with albuterol from 2005 to 2015. Guideline-based care, defined as (1) corticosteroids, (2) no antibiotics, and (3) no CXR, was assessed for each visit. Hospitals were categorized as pediatric or general and compared according to rates of guideline-based care. Multivariable analyses were used to identify demographic and hospital-level characteristics associated with guideline-based care. More than 7 million ED visits met eligibility criteria. Antibiotic provision and CXR acquisition were significantly higher in general EDs (20% vs 11%, 40% vs 26%, respectively), while steroid provision was similar (63% vs 62%). Overall, 34% of visits involved guideline-based care, with a higher rate for pediatric EDs compared with general EDs (42% to 31%). Visit at a pediatric ED (odds ratio, 1.62 [confidence interval 1.17-2.25]) and black race (odds ratio, 1.48 [confidence interval 1.07-2.02]) were independently associated with guideline-based care in a multivariate analysis. Guideline-based care was more common in pediatric EDs, although only one-third of all pediatric-age visits met the definition of guideline-based care. Future policy and education efforts to reduce unnecessary antibiotic and CXR use for children with asthma are warranted.

Trends in Use of Daily Chest Radiographs Among US Adults Receiving Mechanical Ventilation

Guidelines from December 2011 recommended against obtaining daily chest radiographs (CXRs) for patients requiring mechanical ventilation (MV). Daily CXR use for patients receiving MV in US hospitals is unknown and, if high, may represent an opportunity to reduce low-value care and unnecessary radiation. To determine frequency of daily CXR use for US patients receiving MV, assess variability across hospitals, and evaluate whether use has decreased over time. Retrospective cohort study of hospitalized adults (aged ≥18 years) receiving MV for 3 days or longer. Mechanical ventilation was defined by having an International Classification of Diseases, Ninth Revision, Clinical Modification code of 96.7x and an MV charge on more than 1 hospital day. Hospital discharges in the Premier Perspectives database were examined from July 1, 2008, to December 31, 2014. Data analysis was conducted from July 28, 2017, to December 13, 2017. Hospital discharge date (quarter of the year) and hospital in which patients received MV. The outcome was daily CXR use (up to 7 days) during MV. We used standard statistics to describe CXR use, multilevel multivariable regression modeling with adjusted median odds ratio (OR) to evaluate variability by hospital, and multivariable piecewise regression (breakpoint: fourth quarter of 2011) with adjusted OR to evaluate time trends and response to guideline recommendations. The primary cohort included 512 518 patients receiving MV (mean [SD] age, 63.0 [16.1] years; 46% female) in 416 hospitals, of whom 321 093 (63%) received daily CXRs. Wide variability was seen across hospitals; hospitals performed daily CXRs on a median of 66% of patients (interquartile range, 50%-77%; full range, 12%-97%). The adjusted median OR was 2.43 (95% CI, 2.29-2.59), suggesting the same patient had 2.43-fold higher odds of receiving a daily CXR if admitted to a higher- vs lower-use hospital; the odds of receiving daily CXRs were unchanged through quarter 3 of 2011 (adjusted OR, 1.00; 95% CI, 0.99-1.01), after which there was a 3% relative reduction in the odds of daily CXR use per quarter (adjusted OR, 0.97; 95% CI, 0.96-0.98). Three-fifths of US patients receiving MV also received daily CXRs from 2008 to 2014, although use declined slowly after new guidelines were published. The hospital at which a patient received care was associated with the odds of daily CXR receipt.

Successful Chest Radiograph Reduction by Using Quality Improvement Methodology for Children With Asthma.

Implementation of an asthma clinical practice guideline did not achieve desired chest radiograph (CXR) usage goals. We attempt to use quality improvement methodology to decrease the percentage of CXRs obtained for pediatric patients with acute asthma exacerbations from 29.3% to <20% and to evaluate whether decreases in CXR use are associated with decreased antibiotic use. We included all children ≥2 years old at our children's hospital with primary billing codes for asthma from May 2013 to April 2017. A multidisciplinary team tested targeted interventions on the basis of 3 key drivers aimed at reducing CXRs. We used statistical process control charts to study measures. The primary measure was the percentage of patients with an acute asthma exacerbation who were undergoing a CXR. The secondary measure was percentage of patients receiving systemic antibiotics. Balancing measures were all-cause, 3-day return emergency department visits and the percentage of pneumonia and/or asthma codiagnosis encounters. We included 6680 consecutive patients with 1539 CXRs. Implementation of an asthma clinical practice guideline was associated with decreased CXR use from 29.3% to 23.0%. Targeted interventions were associated with further reduction to 16.0%. For subset analyses, CXR use decreased from 21.3% to 12.5% for treat-and-release patients and from 53.5% to 31.1% for admitted patients. Antibiotic use varied slightly without temporal association with interventions or CXR reduction. There were no adverse changes in balancing measures. Quality improvement methodology and targeted interventions are associated with a sustained reduction in CXR use in pediatric patients with acute asthma exacerbations. Reduction of CXRs is not associated with decreased antibiotic use.

A Report of an Asthma Pathway Leading to Improved Resource Use.

Asthma pathways have been shown to improve resource use and decrease length of stay (LOS). A tertiary care hospital implemented an asthma pathway in May 2015 to standardize inpatient care. We predicted that the pathway would increase the use of albuterol metered-dose inhalers (MDIs) and steroids; decrease use of albuterol nebulizer, antibiotics, chest radiograph (CXR), and respiratory viral panel (RVP); and decrease LOS. This retrospective cohort study selected patients between the ages of 2 and 18 years who were admitted for asthma as a primary diagnosis between May 2014 and May 2016 (1 year preimplementation to 1 year postimplementation). Patients' complex chronic conditions were excluded. We analyzed use of albuterol nebulizer, MDI, and continuous nebulization, ipratropium bromide, oral steroids, antibiotics, inhaled steroids, CXR, and RVP. We also evaluated LOS and readmission rate. There were 1131 and 925 patients identified before and after asthma pathway implementation, respectively. The percent that received albuterol nebulizer decreased from 14.1% to 6.1% (p < 0.001). The percent that received albuterol MDI increased from 97.0% to 99.4% (p < 0.001). The average number of MDI administrations decreased from 11.6 to 10.4 (p = 0.004). Continuous albuterol use increased from 52.3% to 59.1% (p = 0.002). There was no change in ipratropium bromide, oral steroid, inhaled steroid, or CXR use. Antibiotic (p = 0.049) and RVP (p = 0.03) use decreased. The average LOS decreased from 1.84 days to 1.71 days (p = 0.02). Readmission rates did not change significantly. The asthma pathway improved inpatient albuterol MDI use. The LOS decreased while maintaining readmission rates.

LO80: Chest radiograph ordering for acute asthma presentations to emergency departments in Alberta: regional, site, and physician level variation

Introduction: Most acute asthma presentations to the emergency department (ED) are uncomplicated and do not require chest radiographs (CXR). Evidence suggests that the proportion of acute asthma patients receiving CXRs in the ED is high and varies substantially within and across sites and studies. This study explored CXR ordering and variation in acute asthma presentations to Alberta’s EDs. Methods: Administrative health data for Alberta was obtained from the National Ambulatory Care Reporting System (NACRS) for all adult (&amp;gt;17 years) acute asthma (ICD-10-CA: J45) ED visits from 2011-2015. Patients with a primary or secondary diagnosis of asthma were included, provided they had a Canadian Triage and Acuity Scale score of 2-5. NACRS data were linked with Alberta Health Services’ (AHS) diagnostic imaging database. Preliminary analysis on variation in imaging at the zone, ED site, and physician level was completed using SAS (v.9.4). Physicians who saw less than an average of 10 asthma patients per year were excluded. Results: Overall, 51,511 acute asthma ED presentations occurred (~10,000/year). The average proportion of CXRs among presentations was 39.5% (2011-2015) with an average annual increase of 6.7%. From 2011-2015, CXR ordering varied across the five AHS zones (variation [V]: 25%; range: 26.0%-51.0%). Substantial variation was observed across ED sites V: 60%; range: 5.9-66.4%) and physicians (V: 89%; range: 1.4-90.6%). The mean CXR ordering among physicians was 44%. Conclusion: From 2011-2015, CXR use among acute asthma ED presentations has increased. Substantial variation in CXR use suggests that evidence-based interventions are needed to improve imaging appropriateness.

Utilization of Thoracic Ultrasound for Confirmation of Central Venous Catheter Placement and Exclusion of Pneumothorax: A Novel Technique in Real-Time Application.

To evaluate the safety and utility of ultrasonography as a tool to confirm central venous catheter (CVC) position and to exclude insertion-related pneumothorax in place of chest radiography (CXR) in a tertiary medical intensive care unit (ICU). We randomized 60 consecutive medical ICU patients to conventional or ultrasound groups for CVC placement. Both groups had CVCs inserted under ultrasound guidance. The intervention group underwent real-time transthoracic echocardiography to assist in catheter positioning and chest ultrasonography for exclusion of pneumothorax. Our primary end point was reduction in CXR use. The secondary end point was time elapsed from the end of procedure to the availability of CVC for use. χ2 test was used to compare the 2 groups for the primary end point. T test was used to compare the 2 groups for the secondary end point. Thirty patients were randomized to the conventional group and 30 were randomized to the ultrasound group. One patient was excluded in the control group since the procedure needed to be aborted. Patient characteristics were well matched for age, body mass index, and acute physiologic assessment and chronic health evaluation (APACHE III) scores. There was a 56.7% ( P < .0001) reduction in CXR use in the ultrasound arm. Mean time to use was 53.6 minutes in the control group and 25 minutes in the ultrasound arm ( P = .0015). Mean time required to complete the procedure was 27.7 minutes in the control group and 24.1 minutes in the ultrasound group ( P = .2053). No pneumothorax was detected in either arm. Ultrasound-guided CVC placement and positioning with a minor modification in technique reduced the use of bedside CXR and reduced the time to use of the CVC.

Feasibility and Safety of Substituting Lung Ultrasonography for Chest Radiography When Diagnosing Pneumonia in Children: A Randomized Controlled Trial

Chest radiography (CXR) is the test of choice for diagnosing pneumonia. Lung ultrasonography (LUS) has been shown to be accurate for diagnosing pneumonia in children and may be an alternative to CXR. Our objective was to determine the feasibility and safety of substituting LUS for CXR when evaluating children suspected of having pneumonia. We conducted a randomized control trial comparing LUS with CXR in 191 children from birth to 21 years of age suspected of having pneumonia in an ED. Patients in the investigational arm underwent LUS. If there was clinical uncertaintyafter ultrasonography, physicians had the option to perform CXR. Patients in thecontrol arm underwent sequential imaging with CXR followed by LUS. The primary outcomewas the rate of CXR reduction; secondary outcomes were missed pneumonia, subsequent unscheduled health-care visits, and adverse events between the investigational and control arms. There was a 38.8%reduction (95%CI, 30.0%-48.9%) in CXR among investigational subjects compared with no reduction (95%CI, 0.0%-3.6%) in the control group. Novice and experienced physician-sonologists achieved 30.0%and 60.6%reduction in CXR use, respectively. There were no cases of missed pneumonia among all study participants (investigational arm, 0.0%: 95%CI, 0.0%-2.9%; control arm, 0.0%: 95%CI, 0.0%-3.0%), or differences in adverse events, or subsequent unscheduled health-care visits between arms. It may be feasible and safe to substitute LUS for CXR when evaluating children suspected of having pneumonia with no missed cases of pneumonia or increase in rates of adverse events. ClinicalTrials.gov; No.: NCT01654887; URL: www.clinicaltrials.gov.

Variation in the Use of Chest Radiography for Pneumonia in Pediatric Emergency Departments

We sought to examine the utilization of chest radiography among children with pneumonia and other respiratory illnesses and to investigate interinstitution chest radiograph (CXR) utilization to identify if there is a relationship between CXR utilization and rate of pneumonia. This is a retrospective study of children evaluated in an emergency department at 25 institutions contributing information to the Pediatric Health Information System database from 2003 to 2008. The use of chest radiographs was determined for patients with a diagnosis of pneumonia, upper respiratory tract illness, wheeze, and fever. Over a 6-year period, pneumonia accounted for 2.1% of all visits to an emergency department. Comparing institutions, the proportion of children with a diagnosis of pneumonia who had a CXR obtained ranged from 38% to 88%. There was no observed association between CXR utilization rate and the proportion of patients with a diagnosis of pneumonia between institutions. There was also a wide variation in the use of CXR for other diagnoses (upper respiratory tract infection [range, 9%-36%], wheeze [14%-56%], fever [7%-41%]). Eighty-percent of children hospitalized with pneumonia had a radiograph obtained, compared with 76% of children with pneumonia discharged from the ED (P = 0.28). However, the rate of utilization of CXR for patients hospitalized with other diagnoses was higher than respective rates of CXR use for discharged patients (upper respiratory tract infection, 68% vs 16% [P < 0.001]; wheeze, 57% vs 23% [P < 0.001]; and fever, 45% vs 18% [P < 0.001]). The use of CXR varies widely among pediatric emergency departments but does not appear to influence the institution-specific rate of pneumonia.