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Reducing Unnecessary Imaging for Patients With Constipation in the Pediatric Emergency Department
Catherine Craun Ferguson1, Matthew P Gray2, Melissa Diaz2
1Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and cferguson@mcw.edu.
Insights
Pediatric emergency departments (EDs) reduced abdominal X-rays (AXRs) for constipation by implementing targeted interventions. This initiative successfully decreased AXR use in children diagnosed with constipation, improving diagnostic efficiency.
Area of Science:
- Pediatric Emergency Medicine
- Radiology Utilization
- Quality Improvement Science
Background:
- Constipation is a frequent reason for pediatric emergency department (ED) visits.
- Abdominal radiographs (AXRs) are often used for diagnosing constipation, despite evidence suggesting they are unnecessary and potentially misleading.
- Current AXR utilization for constipation in a pediatric ED is high, at 60% for low-acuity patients.
Purpose of the Study:
- To decrease the percentage of low-acuity patients (6 months to 18 years) diagnosed with constipation who undergo an AXR in a pediatric ED.
- The target reduction was from 60% to 20% over a 12-month period.
Main Methods:
- An interventional quality improvement project was conducted in a large, urban pediatric ED.
- The Institute for Healthcare Improvement's Model for Improvement guided the project.
- Statistical process control (SPC) charts with rational subgrouping and stratification were used for analysis and intervention targeting.
Main Results:
- Four plan-do-study-act cycles were completed over 9 months.
- Interventions included educational initiatives, best practice sharing, and performance metrics reporting.
- A significant and sustained decrease in AXR utilization for constipation was observed, from a mean rate of 62% to 24% over 12 months.
Conclusions:
- Targeted interventions, informed by SPC analysis of provider groups, effectively reduced AXR use for constipation in a pediatric ED.
- The project demonstrated a substantial and sustained improvement in appropriate diagnostic imaging practices.
Objectives:
Constipation is a common diagnosis in the pediatric emergency department (ED). Children diagnosed with constipation may undergo an abdominal radiograph (AXR) as part of their diagnostic workup despite studies that suggest that an AXR in a patient suspected of being constipated is unnecessary and potentially misleading. We aimed to decrease the percentage of low-acuity patients aged between 6 months and 18 years diagnosed with constipation who undergo an AXR in our pediatric ED from 60% to 20% over 12 months.
Methods:
We conducted an interventional improvement project at a large, urban pediatric ED by using the Institute for Healthcare Improvement's Model for Improvement. The primary outcome was the proportion of patients ultimately diagnosed with constipation who had an AXR during their ED visit. Analysis was performed by using rational subgrouping and stratification on statistical process control (SPC) charts.
Results:
Process analysis was performed by using a cause-and-effect diagram. Four plan-do-study-act cycles were completed over 9 months. Interventions included holding Grand Rounds on constipation, sharing best practices, metrics reporting, and academic detailing. Rational subgrouping and stratification on SPC charts were used to target the interventions to different ED provider groups. Over 12 months, we observed a significant and sustained decrease from a mean rate of 62% to a mean rate of 24% in the utilization of AXRs in the ED for patients with constipation.
Conclusions:
The use of rational subgrouping and stratification on SPC charts to study different ED provider groups resulted in a substantial and sustained reduction in the rate of AXRs for constipation.
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