690 - Improving Viral Testing Practices in the Pediatric ED

Publication Number: 3667.690

Karen Yaphockun, UCSD/RCHSD, San Diego, CA, United States; Yvette Wang, Rady Children's Hospital San Diego, San Diego, CA, United States; Scott Herskovitz, Rady Children's Hospital San Diego, San Diego, CA, United States; Alice Pong, University of California, San Diego School of Medicine, San Diego, CA, United States; Amy Bryl, University of California, San Diego and Rady Children’s Hospital San Diego, San Diego, CA, United States

Background: The American Academy of Pediatrics' (AAP) Choosing Wisely campaign advises against obtaining comprehensive viral panel testing in patients with suspected respiratory viral illnesses, as results rarely change clinical management while adding unnecessary discomfort and cost. At Rady Children's Hospital San Diego (RCHSD), ordering of respiratory pathogen panels (RP2) increased from a pre-COVID pandemic baseline of 1.2 tests per 100 ED visits between January 2019 and February 2020 to 6.7 tests per 100 visits between July 2023 and April 2024. This quality improvement initiative aims to reduce RP2 testing and align ED practice with Choosing Wisely recommendations.

Objective: The global aim of this project is to improve clinical practices and mitigate the growing problem of unnecessary testing in pediatric emergency departments. The SMART aim is to reduce RP2 ordering in the ED from 6.7 to ≤5 tests per 100 visits by May 31, 2025.

Design/Methods: A key driver diagram guided intervention planning and implementation (Figure 1). The primary measure is the proportion of RP2 tests ordered per 100 visits. Outcome measure was appropriate antimicrobial prescribing for treatment-available positives (Influenza, Mycoplasma and Chlamydia pneumoniae). Balancing measure was 72-hour return visits and other viral test utilization. Interventions included provider education promoting judicious testing, creation of a Mycoplasma testing and treatment algorithm during the Mycoplasma outbreak, quarterly individualized feedback using funnel plots, and outreach to high test utilizers. We used statistical process control to monitor changes in measures over time.

Results: Over the course of this QI initiative, the proportion of RP2 tests ordered per 100 visits decreased from 6.7 to 4.9 with 2 CL shifts (Figure 2). The proportion of RP2s ordered through reflex testing increased from 26% to 34% (Figure 3). The proportion of appropriate prescriptions provided for positive test results increased from 36% to 45%. The proportion of return visits of all ED patients discharged within 72 hours remained unchanged at 4%.

Conclusion(s): Using QI methodology, we improved alignment with the AAP's ED-specific Choosing Wisely campaign by reducing comprehensive viral testing through routine education, promotion of cost-effective alternative testing approaches for illnesses requiring antimicrobial treatment, and individualized feedback. We continue to monitor data to ensure sustained improvement.

Key Driver Diagram (KDD)
Improving Viral Testing Practices in the Pediatric ED KDD

Proportion RP2 Test Ordered per 100 ED Encounters U Chart
RP2 tests ordered per 100 visits decreased from 6.7 to 4.9.

Proportion RP2 Tests Ordered via Reflex P Chart
The proportion of RP2s ordered through reflex testing increased from 26% to 34%.