BACKGROUND:

Although pharyngitis is common, group A Streptococcus is an uncommon etiology, and sequelae are rare in patients <3 years old. Inappropriate testing leads to increased cost of health care and unnecessary exposure to antibiotics. Rapid streptococcal tests (RSTs) for group A Streptococcus pharyngitis are not routinely indicated in this age group. At our urban, tertiary pediatric emergency department (ED), on average, 20 RSTs were performed each month for patients <3 years of age. Our objective was to reduce RSTs in the ED in patients aged <3 years by 50% in 18 months.

METHODS:

We initiated this project in October 2016 at an urban, tertiary pediatric ED. We surveyed pertinent multidisciplinary stakeholders to identify factors leading to RSTs in children <3 years of age. We conducted multiple interventions and collected weekly data on the number of RSTs in children aged <3 years (outcome measure) and the number of family complaints and return visits for complications of pharyngitis (balancing measure). We used statistical process control for analysis.

RESULTS:

The mean number of RSTs ordered per month in patients aged <3 years declined by 52% in 10 months. The majority of tests during the study phase were ordered by nurse practitioners (62%) for patients aged 25 to 36 months (66%). There has been 1 family grievance and no patient complications attributable to the project.

CONCLUSIONS:

Our interventions led to a successful and sustained reduction of RSTs in patients aged <3 years. A local clinical practice guideline was developed, and the project was expanded to other acute care settings.

There are 12 million outpatient pediatric visits per year for sore throat, accounting for $224 million to$539 million per year in health care–related costs.1,2  Streptococcal pharyngitis is common in the pediatric population; however, in patients aged <3 years, group A Streptococcus (GAS) is a rare cause of sore throat, and sequelae (such as acute rheumatic fever) are rare.3  Inappropriate testing leads to increased cost of health care and unnecessary exposure to antibiotics. At our urban, tertiary pediatric emergency department (ED), 242 rapid streptococcal tests (RSTs) were ordered for patients aged <3 years from October 1, 2015, to September 30, 2016, for an average of 20.1 tests per month.

According to the national guidelines published by the Infectious Diseases Society of America (IDSA) in 2012, RSTs for GAS pharyngitis are not routinely indicated in this age group unless the patient both meets clinical criteria and has a household contact with documented streptococcal pharyngitis.4  Despite strong recommendations from national committees, including the IDSA, against routinely testing patients aged <3 years, there is a gap in clinical practice for ordering RSTs at our local institution.5

On the basis of information gathered with our baseline data, including surveys and key stakeholder opinions, we identified gaps (namely lack of knowledge and retention and family expectation) and designed interventions to address them. Our multidisciplinary quality improvement (QI) team used a variety of methods to understand factors leading to ordering RSTs. This allowed us to develop multiple sequential interventions to reduce testing in this population. Another identified gap was the need for reminders, and we developed a mechanism for in-person reminders for the short-term and focused reminders in the ordering process as a more sustainable intervention. Lastly, interventions were designed to address family questions and expectations from ED management. We believed this multipronged and targeted approach would be best suited to optimize the ordering of testing.

Our aim with this multidisciplinary project was to reduce the mean number of RSTs ordered per month in the ED in patients aged <3 years by 50% over 18 months between October 1, 2016, and March 31, 2018.

The Children’s Mercy Kansas City ED at the Adele Hall Campus is an urban, tertiary pediatric ED with 75 000 visits annually. Medical providers in the ED include faculty physicians trained in pediatric emergency medicine (PEM), pediatrics and/or emergency medicine physicians, resident physicians (pediatrics, internal medicine–pediatrics, emergency medicine, and family medicine), fellows (PEM, hospital medicine, and child abuse and neglect), medical students, and nurse practitioners (NPs). The patients are triaged according to the Emergency Severity Index criteria and roomed accordingly in 1 of 3 different zones of the ED. NPs see a large number of low-acuity patients, including those who present with sore throat.

We assembled an interdisciplinary team of personnel, including 3 ED nurses (Jacque Brown, Angela Wiedner, and Amy Scott), 2 ED NPs (J.M. and J.E.-S.), 2 PEM attending physicians (S.J. and Theodore Barnett), 1 PEM fellow (T.A.), and 2 pediatric infectious diseases (ID) physicians (L.N. and A.M.). One PEM attending with formal QI training also served as quality consultant.

Our team surveyed representatives from pertinent disciplines (NPs, nurses, PEM physicians, pediatric ID physicians, and PEM leadership) to identify factors leading to RSTs in this age group. With this information, we built a process map and key driver diagram to identify gaps and build interventions. Figure 1 shows our process map for pharyngitis diagnosis at baseline, with highlighted areas representing opportunities for educational intervention. We found that lack of knowledge and/or retention, family expectations, and practices driven by adult literature were all factors in choosing to obtain an RST. We developed multiple sequential interventions on the basis of focused discussions with key stakeholders (PEM physicians, PEM fellows, NPs, and nurses) as well as expert opinion from PEM and ID faculty and PEM management. The order of interventions was based on the discussions with stakeholders as well as the interventions’ feasibility and importance.

FIGURE 1

Flow diagram for RSTs in patients <3 years old. This figure shows our process map for pharyngitis diagnosis at baseline. The bar on the left shows the patient, bedside nurse, and provider. The highlighted areas represent opportunities for educational intervention.

FIGURE 1

Flow diagram for RSTs in patients <3 years old. This figure shows our process map for pharyngitis diagnosis at baseline. The bar on the left shows the patient, bedside nurse, and provider. The highlighted areas represent opportunities for educational intervention.

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Elements of the interventions are as follows.

1. Provider education: PEM physicians, fellows, and NPs were included. We used several forums for this purpose, including division meetings, huddles, and emails, and created educational handouts. We chose provider education for the first step on the basis of feedback from the QI team, who wanted to start with education and culture change before instituting any changes to the ordering process. Education was important because it enabled us to identify more champions for the project and allowed for repeat educational sessions for newer staff. We also conducted 3 focused discussions with the champions to provide continued education and feedback.

2. Nursing education: Education for nurses was focused on reminders about RST guidelines at weekly huddles, informational posters about streptococcal pharyngitis and RST guidelines in the staff break room, and education about the existing standing order for RSTs. This step was particularly important because RSTs at our institution may be performed in triage by the nurses. It also served as an opportunity for the nurses to review other standing orders in place at our institution with the new staff.

3. Daily management system (DMS) and lean process: Our ED uses DMS, a structured management system that includes visual boards, huddles, leadership support, continuous improvement, and methodical problem-solving to ensure consistent and reliable service for patients. We used our DMS process for this project to provide weekly visual updates about the number of RSTs obtained in children <3 years in the previous week, which were attended daily by physician, nursing, and NP representatives. This visual step was important to increase the awareness of inappropriate RSTs, provide education, gather support for the project, and offer frequent reminders to the front-line staff about the RST guidelines.

4. Resident education: Education for residents included an annual case-based didactic lecture during the project time frame and a short educational session at a housestaff meeting. There was informal education provided by supervising physicians during clinical shifts if a resident considered ordering an RST in a patient <3 years. Residents were also provided with resources, including relevant journal articles.

5. Computerized order process alert: We used our electronic medical record (EMR) system (Cerner, North Kansas City, MO) to create a real-time alert and reminder. When an RST order was placed on a patient <3 years old, an alert would remind the user of the recommendations about when RSTs are appropriate. It would also ask the user to either cancel the test or select a rationale for ordering the test among the following options: recent exposure to a sick contact with documented streptococcal pharyngitis, parent and/or guardian requesting the test, or other (qualitative free-text response). The user had the opportunity to review Centers for Disease Control and Prevention guidelines for RSTs.

6. Family education: We modified an existing handout for families that was taken from a different QI project focused on improving guideline-based streptococcal pharyngitis testing at a private practice6  (Supplemental Fig 4). Family education also included sample dialogue for NPs to discuss streptococcal pharyngitis testing with families. This step was considered important to engage families in an educated decision-making process and in light of the responses gathered from the RST order process alert (parent and/or guardian requesting the test).

We collected weekly RST data in addition to data on family complaints, admissions, and return visits within 7 days for complications of pharyngitis. For our outcome measure, we chose the number of RSTs ordered per month in patients aged <3 years. Although having patients with pharyngitis as the denominator would have been ideal and was considered, identifying such visits from our data was not feasible. This decision was based on several confounders, including the variability in documentation of diagnoses. We were able to collect data on the proportion of appropriate testing with data from our computerized process alert for a portion of the study. On the basis of the IDSA guidelines, there is only a small proportion of testing in this age group that would be considered appropriate; hence, we chose to track the number of tests per month. We chose our process measure to be the total number of canceled tests in patients aged <3 years, which we determined from the order process alert. The order alerts including reasons for ordering and canceling RSTs provided useful process information. The data from the outcome and process measure were collected from our EMR system. To ensure that the decrease in RSTs did not negatively impact other ED metrics, the balancing measure was the number of grievances reported to the hospital’s patient advocacy department and the number of admissions or return visits for complications of pharyngitis within 7 days of the patient’s initial visit.

We established a baseline between October 1, 2015, and September 30, 2016, on which to test improvement. Once baseline data were established, we initiated our interventions, starting with education, in October 2016. We achieved our goal of reducing RSTs by 50% in 10 months and wanted to monitor sustainability in the busy winter and spring seasons. We used failure modes and effects analysis principles and closely monitored the data for an additional 8 months. We did not have stop rules a priori. We chose the lengthy duration of the entire project to negate the effect of seasonal variation in presentation and testing for pharyngitis. We obtained a monthly report of the number of RSTs ordered. All streptococcal testing was performed in the microbiology laboratory, and results were reported in the EMR. We validated the data with corroborative information from the microbiology laboratory and regularly checked the data for accuracy and completeness. Each month, the authors reviewed a random sample of patient charts with RSTs associated to check for data accuracy. This enabled us to refine the automated data collection and provided an opportunity to inform our interventions including timely education.

We used Microsoft Excel and QI Macros to develop statistical process control charts for analysis and document plan-do-study-act cycles for interventions. We agreed on using the statistical control QI chart rule of having 8 points on either side of the process mean for discerning special versus common cause.7,8  The project was initiated after receiving an institutional review board exemption. The board determined that it met criteria to be classified as a QI project.

Our baseline data from October 1, 2015, to September 30, 2016, showed that 242 RSTs were ordered on patients <3 years old. The baseline mean was 20.1 tests per month over 12 months. Most of the tests were ordered by NPs (69%), followed by residents (13%) and attending physicians (10%). Tests were ordered for patients aged 25 to 36 months (77%) and 13 to 24 months (23%).

The mean number of RSTs ordered per month in patients aged <3 years declined by 52% over 10 months, from 20.1 to 9.8 per month. The results for the outcome measure are shown in a control chart in Fig 2. Most of the tests during the study period were ordered by NPs (62%), followed by residents (21%), faculty (10%), nurses (3%), medical students (2%), and fellows (2%). Figure 3 shows the cumulative results for RSTs by ordering personnel for the entire data set analyzed. Tests were ordered for patients aged 25 to 36 months (66%), 13 to 24 months (31%), and ≤12 months (0.03%). The majority of patients were white (34%) and African American (29%), and 55% of patients were boys.

FIGURE 2

Control chart for RSTs in patients <3 years old. Shown is a c-chart for the number of RSTs ordered for patients <3 years old. CL, control limit; LCL, lower control limit; UCL, upper control limit.

FIGURE 2

Control chart for RSTs in patients <3 years old. Shown is a c-chart for the number of RSTs ordered for patients <3 years old. CL, control limit; LCL, lower control limit; UCL, upper control limit.

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FIGURE 3

RST by ordering provider. A Pareto chart shows the ordering personnel who ordered the RST. Sixty-six percent of tests were ordered by NPs.

FIGURE 3

RST by ordering provider. A Pareto chart shows the ordering personnel who ordered the RST. Sixty-six percent of tests were ordered by NPs.

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Results from the RST order process alert starting in April 2017 showed that symptoms consistent with streptococcal pharyngitis and a recent sick contact with GAS were the reported reasons for RSTs in 43% cases. Parental and/or guardian request was the reason for testing in 23% of patients. The remaining 33% of patients had RSTs ordered for a variety of other reasons. Qualitative data indicated that almost one-quarter of parents or guardians requested RSTs, leading us to use a family-centered educational handout on pharyngitis for families.

Of the patients with RSTs, 25% had a positive result. Using data on this group from the order process alert, we found that 40% had symptoms of pharyngitis and a recent exposure to GAS, and 33% had a parent and/or guardian requesting the test. The remaining 27% of patients had RSTs ordered for symptoms alone.

Ultimately, our process measure showed that 11 (7%) RSTs were canceled. Our balance measures revealed 1 grievance for a patient <3 years old presenting with sore throat and no RST in our ED who was later found to have a positive test result at his primary care physician’s office. Although there was a patient who presented initially with a peritonsillar abscess, there were no patients who developed a complication as a result of not having an RST performed at their initial ED visit.

In a busy academic pediatric ED, we used QI methodology to reduce RSTs in patients <3 years old by 52% in 10 months. We monitored our data for an additional 8 months, and the successful reduction has been sustained. Our interventions led to a significant decline in RSTs in this population without a significant increase in streptococcal pharyngitis–related admissions, return visits, or grievances. Although 1 patient had a peritonsillar abscess, robust evidence suggests that children present with an abscess at initial presentation rather than as a complication of a missed or delayed diagnosis of streptococcal pharyngitis.1,9,10

Key interventions involved education for health care providers and families about GAS, the use of DMS, and an order process alert. The success of this project was largely due to an interdisciplinary approach and an interest in practice improvement. The collaboration among physicians, NPs, and nurses, in addition to the partnership between PEM and pediatric ID subspecialists, was a valuable asset. Through educational support and teamwork, we were able to build trust to engage our colleagues in this project. We reviewed data collectively in terms of type of health care provider group without identifying any individual provider, and there were no punitive actions for those who ordered an RST. This project also enabled culture change before process change, specifically by offering education before making changes to our EMR system. We believe the order process alert was a critical and measurable process change. To activate the alert in our EMR, we worked closely with a microbiology information technology champion. We performed a pilot of our customized order prompt, and once successful, we launched it. Of our interventions, the EMR prompt provided the most data regarding rationale for ordering RSTs and helped achieve sustainability in reduced testing. The options allowed us to identify reasons for RSTs, modify the process, and provide feedback if necessary. This information indicated that providers may need additional strategies to better explain the need for testing to caregivers, prompting us to share suggested dialogue techniques with providers and use an educational handout for families.

In December 2017, there was an increase in RSTs, which we attribute to increased testing for influenza and streptococcal pharyngitis during a severe influenza outbreak.10,11  The increase in GAS testing prompted us to conduct further investigation and educational interventions for providers regarding GAS testing guidelines for patients <3 years old. Continuing targeted education for providers with high use may be of benefit.

We developed a structured process, from weekly data collection to educational interventions and the order process alert, that served as the foundation for wider implementation of QI projects focused on reducing RSTs at our institution. Members of our group conducted a similar study in the community setting, which successfully reduced RSTs in patients <3 years old, further suggesting that this project may be generalizable to a variety of settings.6  The scope of these projects has extended to include affiliated urgent-care centers and outpatient settings at the hospital. Additional systems changes were achieved by the development of a hospital-wide clinical practice guideline for diagnosis and treatment of pharyngitis.

Our study was limited by several factors. We did not account for interprovider variability; for example, RSTs may have been ordered more frequently by a single provider compared with their group, and we did not obtain data on individual providers. Second, although we captured return visits to our ED, we were unable to acquire data on return visits to outside hospitals or clinics. Consequently, we do not know if this population had any complications prompting a return medical visit at another facility. Additionally, families may have been unsatisfied with their medical care, specifically with their children not having RSTs, but did not submit a formal grievance. Although our educational interventions may be generalized to other settings, the order process alert may not be appropriate for institutions that lack an EMR. Replication of our interventions may also be hindered by lack of buy-in from key stakeholders at outside institutions.

Although it was not the established foci for this project, we believe this project was impactful for antibiotic and financial stewardship efforts. By reducing RSTs, we in turn may have decreased unnecessary antibiotic use in this population. Additionally, although we did not plan this as a cost-saving project, a reduction in the number of RSTs and streptococcal cultures led to a $2200-per-month reduction in health care costs, from$3781 per month at baseline to \$1580 per month since starting the project. Patient charges may differ, and these costs do not include the antibiotics or the charges the patient would incur with a health care visit due to adverse events from them.

We used QI methodology to reduce RSTs for patients aged <3 years. Our interventions were focused on education for health care providers and families and used lean processes. Collectively, our interventions led to a significant reduction of RSTs in patients in this age group. We believe that early collaboration with stakeholders led to provider buy-in, which was a key driver of success. The success of the project has remained sustained. Our findings suggest that other sites might also achieve reductions in RSTs in this age group by focusing on a similar interdisciplinary approach. We have implemented additional systems changes, including a clinical practice guideline for pharyngitis. Additionally, we have expanded this project to include affiliated urgent-care centers and all outpatient settings at the hospital.

We send a special thank you to our QI team: Jacque Brown, Angela Wiedner, Theodore Barnett, and Amy Scott.

Dr Ahluwalia made substantial contributions to the study, including the conceptualization and design, methodology, investigation, data curation, formal analysis, and resources, and participated in drafting the initial manuscript; Drs Jain and Myers made substantial contributions to the study, including the conceptualization and design, methodology, investigation, supervision and oversight, data curation, formal analysis, and resources, and participated in drafting the initial manuscript; Dr Norton made substantial contributions to the study, including the methodology, investigation, and resources; Ms Meade and Ms Etherton-Still made contributions to the study, including the methodology and investigation; and all authors reviewed or edited the manuscript, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.

This work was presented in part at the American Academy of Pediatrics National Conference and Exhibition; September 16–19, 2017; Chicago, IL; and at the Pediatric Academic Society Annual Meeting; May 5–8, 2018; Toronto, ON.

Dr Ahluwalia’s current affiliation is Children’s National Medical Center, Washington, District of Columbia.

FUNDING: No external funding.

DMS

daily management system

ED

emergency department

EMR

electronic medical record

GAS

group A Streptococcus

ID

infectious diseases

IDSA

Infectious Diseases Society of America

NP

nurse practitioner

PEM

pediatric emergency medicine

QI

quality improvement

RST

rapid streptococcal test

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## Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.