543 - Reducing Chest Radiograph Utilization in Infants with Bronchiolitis Through Quality Improvement Initiatives

Publication Number: 2528.543

Erica Potts, Dayton Children's Hospital, OAKWOOD, OH, United States; Aleeya Shareef, Dayton Childrens Hospital, Wright State University, Dayton, OH, United States; Lisa Ziemnik, Dayton Children's Hospital, Dayton, OH, United States; Jeremy T. Larson, Dayton Children's Hospital, Bellbrook, OH, United States; Brian Forster, Dayton Children's Hospital, Dayton, OH, United States; Timothy T. Phamduy, Dayton Children's Hospital, Dayton, OH, United States

Background: Chest radiographs (CXRs) are frequently overused in children with bronchiolitis, despite the American Academy of Pediatrics' Choosing Wisely campaign advising against routine imaging in uncomplicated cases. Unnecessary chest X-rays can contribute to increased healthcare costs, expose patients to avoidable radiation, and lead to misdiagnoses that may in turn result in unwarranted antibiotic use.

Objective: To reduce the rate of CXR use in low-risk bronchiolitis patients in the emergency department (ED) at a freestanding children's hospital.

Design/Methods: A multidisciplinary team was assembled to identify drivers of CXR overuse. Interventions included provider education, highlighting clinical guidelines, and feedback on individual and team imaging rates. Data were collected retrospectively and prospectively using institutional quality dashboards as well as chart reviews. The primary outcome was the proportion of low-risk bronchiolitis encounters with a CXR obtained.

Results: Within two months of implementation, the CXR rate decreased from a baseline of 34% to 20%. This reduction was sustained over the following two months. There were no increases observed in revisit rates or hospital admissions, suggesting safety was maintained.

Conclusion(s): Targeted QI interventions significantly and sustainably reduced unnecessary chest imaging in infants with bronchiolitis without compromising patient outcomes. These findings support the value of education and system-level changes in aligning care with evidence-based guidelines.

Rate of Radiographs in Low-Risk Bronchiolitis Encounters
Figure 1. Control Chart of Chest Radiograph Use in Low-Risk Bronchiolitis Encounters
Weekly control chart showing the percentage of low-risk bronchiolitis encounters with a chest radiograph. Interventions (e.g., provider education, posters, and plan-do-study-act [PDSA] emails) correspond with sustained reductions in imaging rates. Goal (green), mean (red), and control limits (dashed) shown.

Distribution of Return Visits by Chest Radiograph Use Before and During QI Intervention
Figure 2: Distribution of Return Visits by Chest Radiograph Use Before and During QI Intervention: Pie chart displaying the distribution of ED return visits and non-returns stratified by chest radiograph (CXR) use, comparing pre-intervention and during-intervention periods. Each segment represents a proportion of low-risk bronchiolitis encounters, grouped into those who had a return visit (return) or not (NoR), and whether a CXR was ordered (XR+) or not (XR-). The QI initiative period (QI) demonstrated lower return rates, supporting CXR reduction as safe and sustainable. Data reflect balancing measure analysis from a random sample of pre- and during-intervention patients.