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When All That Wheezes Is Usually Asthma :

July 11, 2018

Throughout my training I recall being taught, “All that wheezes is not asthma”.

Throughout my training I recall being taught, “All that wheezes is not asthma”. While true, it often is asthma in pediatrics, so much so that more than 800,000 children less than 15 years of age present to the emergency department (ED) each year with asthma-related concerns.  The National Asthma Education and Prevention Program provides guidelines on how to best care for children with acute asthma exacerbations.  One item missing from these guidelines: routine use of chest x-rays.  Routine chest x-rays in children presenting with acute asthma exacerbations for which no alternative diagnosis is clinically suspected can lead to increased costs, unnecessary radiation exposure, and inappropriate administration of antibiotics. 

In this month’s Pediatrics, Watnick et. al. (10.1542/peds.2017-4003) share their experiences from a quality improvement initiative at Monroe Carell Jr. Children’s Hospital at Vanderbilt to reduce the percentage of chest x-rays obtained on patients with acute asthma exacerbations.  The multi-disciplinary team of pediatric hospitalist, emergency medicine specialists, and pulmonary specialist, nurses, nurse practitioners, and respiratory therapists identified three key drivers to reduce the number of chest x-rays ordered: 1) standardization of treatment, 2) electronic ordering that supported asthma practice guideline, and 3) provider education.  To address these  key drivers, team members updated their institution’s asthma practice guideline to reserve chest x-ray use for persistent severe respiratory distress, focal findings not improving after ≥12 hours of standard asthma therapy, or concern for pneumomediastinum or pneumothorax.  Additionally, chest x-rays were removed from the ED’s asthma order set and providers could no longer choose “wheeze” as an indication for obtaining the study.  Key stakeholders were educated on these measures by QI team members and the outcomes were subsequently studied using statistical process control charts.  So, did it work?

Study authors analyzed the percentage of over 6,000 patient visits for acute asthma exacerbations during which a chest x-ray was ordered.  The percentage of chest x-rays obtained was successfully decreased to 16% from a baseline of 29.3% for all-comers to the ED.  When stratified by disposition, the percentage of chest x-ray use declined from 21.3% to 12.5% for patients discharged home from the ED and from 53.5% to 31.1% for admitted patients.  During this same time period, there was no significant change in all cause 3-day return ED visits, suggesting that pathologies requiring a chest x-ray for diagnosis were not missed with fewer x-rays ordered.  While the percentage of patients prescribed antibiotics did not meet the accepted benchmark for EDs (1.4% of all patients), study authors note that the baseline rate for ED patients discharged home and admitted were already low at 2.3% and 12.7%, respectively.  The success of the initiative was sustained over a 14-month period post-intervention.  Do you see a lot of asthma in your practice?  Then check out this article in this month’s Pediatrics to learn more how you might reduce the number of chest x-rays you order for asthma!

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