Background: When a patient presents with chest pain to the primary care pediatrician, the decision to refer can be challenging. Pediatricians need skills in identifying patients who may have underlying cardiac pathology, and in being able to allay concerns for those who do not. In previous studies, primary pediatricians identified gaps in their education surrounding the issue of subspecialty referral, specifically citing a lack of knowledge of the medical red-flags that would necessitate a referral. Furthermore, a recent multi-center initiative identified medical red-flag criteria for chest pain associated with cardiac disease with 100% sensitivity in children ages 7-21 years. Aim: To decrease low probability cardiology referrals in patients ages 7-21 presenting with chest pain to two local pediatric practices from 21% to 5% by 1/1/2019. Methodology/Interventions: For this pilot QI initiative, we assembled a multidisciplinary team consisting of a pediatric cardiologist, pediatricians/ nurses at both primary care practices, and quality improvement support members. (Figure 1) The team designed and implemented an initiative consisting of (1) utilization of a validated screening tool in triaging chest pain in children, (2) development of decision support tool (red-flags for referral) (Figure 2) in electronic medical record, (3) conducting in person pediatrician education, (4) posting notification about decision support tool in work room and touchdown station, (5) linking decision support tool on “sick visit form” and (6) implementing site specific reminders to increase compliance (faculty meeting discussions, webinar). The outcome measure was reducing low probability referrals in children presenting with chest pain to primary pediatric care. The process measure was to increase utilization of decision support tool. Balancing measures were missing life threatening event and/or incidental finding of cardiac disease. We tracked progress via statistical process control charts. Results: Seventy seven patients were enrolled; seventeen pediatricians and two nurse practitioners participated. The outcome goal of low probability cardiology referrals in pediatric patients ages 7-21 who presented with chest pain decreased from 21% to 0%. (Figure 3) The process measure of improved utilization of decision support tool increased from baseline of 0% to 50%. For children with low probability for referral and at a median follow up time of 1.04 (Interquartile range 0.53-1.85) years, the patient safety balancing measures of missing life threatening event and/or incidental finding of cardiac disease were 0% across the entire cohort. Discussion/Conclusion: A quality improvement initiative deployed at local pediatrician offices to reduce low probability referral for children presenting with chest pain was feasible and effective. Evidence-based decision support prompts in the electronic medical record and local champion engagement were key elements for success. Learning lessons from the pilot portion will be utilized in the second phase of the initiative (full launch to all local pediatric practices).

EMR: Electronic medical record

Based on the validated medical red-flag criteria published in the Chest pain Standardized Clinical Assessment and Management Plans (SCAMPs®) paper. Clinical Pediatrics 2017 Nov; 56 (13): 1201-1208. Abbreviations: MI: Myocardial infarction, S2: second heart sound.

Decrease low probability referrals

Decrease low probability referrals

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EMR: Electronic medical record