Reducing Chest Radiographs in Bronchiolitis Through High-Reliability Interventions.

Area of Science:

• Pediatric hospital medicine
• Quality improvement science
• Clinical workflow optimization

Background:

• Bronchiolitis is a major cause of pediatric hospitalization, leading to substantial morbidity and healthcare utilization.
• Current practices often deviate from American Academy of Pediatrics recommendations against routine chest radiographs (CXRs) for bronchiolitis.
• Previous interventions, including guidelines and education, have shown limited success in reducing unnecessary CXR use.

Purpose of the Study:

• To decrease the utilization of chest radiographs (CXRs) for children under two years old diagnosed with bronchiolitis.
• To reduce CXR use from a baseline of 42.1% to below 15% by March 2020.
• To assess the impact of interventions on return emergency department visits.

Main Methods:

• A multidisciplinary team was formed in 2012 to standardize bronchiolitis care.
• Quality improvement science methods and high-reliability interventions were implemented starting in 2017.
• Statistical process control charts monitored CXR use and 72-hour return emergency department visits.

Main Results:

• Over 12,000 bronchiolitis encounters were analyzed from 2012 to 2020.
• Initial low-reliability interventions had unsustained effects on CXR use.
• High-reliability interventions led to sustained reductions in CXR use, from 42.1% to 23.3% and 18.9% in recent years, with no increase in return visits.

Conclusions:

• High-reliability workflow redesign is more effective than educational campaigns for sustained practice change.
• This approach successfully translated clinical recommendations into practice for bronchiolitis care.
• Workflow redesign offers a sustainable method to reduce unnecessary diagnostic imaging in pediatric respiratory infections.