Multidisciplinary ED Decision Tool Curbs Strep Testing in Infants

By Marilynn Larkin

September 12, 2019

NEW YORK (Reuters Health) - Multidisciplinary interventions reduced streptococcal testing by more than half in children under age three in an urban tertiary pediatric emergency department, a new study shows.

"We used the Infectious Diseases Society of America group A streptococcus clinical practice guideline as the basis of our institutional clinical practice guideline and clinical decision support tool, developed for our electronic medical record," Dr. Tania Ahluwalia of Children's National Medical Center in Washington, DC, told Reuters Health by email.

"This led to a (52%) reduction in testing children under the age of three years, who are unlikely to be infected with group A streptococcus and even less likely to develop rheumatic fever," she said.

"Overtesting in young children and those with clear viral symptoms is a problem in the U.S., as it leads to overdiagnosis and treatment of colonized children with viral infection," she noted. "Rheumatic fever, a main reason for testing for streptococcal pharyngitis, is uncommon in the U.S. and other developed nations. However, rheumatic fever has a much larger prevalence in developing countries, where testing and treatment for streptococcal pharyngitis oftentimes is not readily available."

As reported online September 11 in Pediatrics, Dr. Ahluwalia and colleagues started the quality-improvement project in October 2016. They conducted a survey to identify factors leading to rapid streptococcal tests (RSTs) in children <3 years of age, then implemented multiple interventions and collected weekly data on the number of RSTs ordered for these children (outcome measure) and the number of family complaints and return visits for complications of pharyngitis (balancing measure).

Interventions included: (1) provider education; (2) nursing education; (3) use of a structured, daily management system; (4) resident education; (5) computerized order process alerts; and (6) family education.

"We believe the order process alert was a critical and measurable process change," the authors note. "To activate the alert in our EMR, we worked closely with a microbiology information technology champion."

As a result of these efforts, the mean number of RSTs ordered per month in patients under age three declined by 52% in 10 months.

Specifically, baseline data from 2015 to 2016 showed that 242 RSTs were ordered for these children, for a mean of 20.1 tests per month.

Tests were ordered mostly for patients ages 25 to 36 months (77%) and 13 to 24 months (23%).

After the interventions, the mean number of RSTs ordered monthly dropped to 9.8. There was one family grievance and no patient complications attributable to the project.

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

Dr. Ethan Wiener, director of the Division of Pediatric Emergency Medicine at NYU Langone's Hassenfeld Children's Hospital in New York City, commented by email, "This is simply a terrific example of quality improvement science done well."

"The authors initiated this effort with a broad-based understanding of the landscape at their institution both from the perspective of the experience there (baseline data) as well as understanding the perceptions and preferences of the providers in a multidisciplinary, collaborative approach of a good cross section of stakeholders," he told Reuters Health.

"The key driver diagram and the effort in identifying those elements is what allows the success of this project - and any project - and truly informs the interventions, as it did in this case," he said.

"At NYU, we have a variety of quality-improvement projects ongoing that have taken a similar approach," he continued. "We convene stakeholders from different disciplines (nurses, physicians, supply chain, pharmacy, administrative support) to consider various issues and identify areas of opportunity to improve upon a process to drive a desired outcome."

"The basic idea is to reduce variability for things for which there are broadly recognized practice guidelines and to drive behavior to achieve the desired outcome," he said. "It must be discrete, achievable, and measurable to fit this model. Feedback on an ongoing basis to providers is key to maintaining awareness and to its success."

"This process of quality improvement is ongoing in every hospital," he said. "There are always challenges in this pursuit, but the desire and intent to tackle them will always be a primary focus in our institution as it is, fortunately, now in many children's hospitals and hospital systems."


Pediatrics 2019.