The Inaugural Choosing Wisely List for Pediatric Emergency Medicine: Strategies for Local Implementation

Target Audience

Pediatric emergency medicine providers and fellows, acute care pediatricians, acute care advanced practice providers, urgent care providers, family medicine providers, acute care providers, quality and patient safety specialists

Objectives

At the End of this Session, the participant should be able to:

1. Discuss the process for developing and supporting evidence for the Choosing Wisely list of recommendations.
2. Identify barriers and strategies to implementing these recommendations by drafting a cause and effect diagram, an aim statement, and a key driver diagram.  
3. Recognize and define opportunities to implement PEM Choosing Wisely strategies in one’s own practice.

The interactive, small-group-based workshop will have participants drafting QI tools to strategize how to implement the CW recommendations.  A faculty-facilitated small group will be created for each CW recommendation.  Participants will choose their small groups.

Faculty and peer-to-peer information-sharing in small groups will promote an engaging learning environment.  Examples of successful QI initiatives with a cause-and-effect diagram, aim statement, and key driver diagram will be shared as references. Workshop facilitators will leverage ideas generated at this session as the next steps for implementation of the Choosing Wisely recommendations at local, regional, and national levels. 

The Choosing Wisely recommendations for Pediatric Emergency Medicine span a range of subspecialties and have received approval from numerous subspecialty societies.  The content of the recommendations includes radiology (Items 1, 3, and 4), infectious diseases (Items 1 and 5), psychiatry (item 2), neurology (item 3), and gastroenterology (item 4). Specialists in these fields will be stakeholders in the quality improvement implementation process and would benefit from their participation in the workshop.  The content of this inaugural Choosing Wisely list of recommendations is novel and has not been presented at any other conferences.  All workshop faculty are experts in the field of quality improvement and have extensive experience in helping small groups problem-solve on the challenges of implementing best practice recommendations.

Key Resources

Choosing Wisely – United States

Choosing Wisely – Canada

Presenter Contact Information

• Paul Mullan, Children’s Hospital of the King’s Daughters, Norfolk, Virginia, USA – mullan20@gmail.com @paulmullan20 
• Kelly Levasseur, Children’s Hospital of Michigan, Detroit, Michigan, USA – docklevasseur@gmail.com
• Shabnam Jain, Emory University/Children’s Healthcare of Atlanta, Atlanta, Georgia, USA – sjain@emory.edu
• Michele Nypaver, University of Michigan, Ann Arbor, Michigan, USA – michelen@med.umich.edu
• Lalit Bajaj, Children’s Hospital of Colorado, Denver, Colorado, USA – Lalit.Bajaj@childrenscolorado.org
• Jim Chamberlain, Children’s National Medical Center, Washington, DC, USA – JCHAMBER@childrensnational.org
• Olivia Ostrow, Hospital for Sick Children, Toronto, Canada – olivia.ostrow@sickkids.ca
• Jennifer Thull-Freedman, Alberta Children’s Hospital, Calgary, Canada – Jennifer.Thull-Freedman@albertahealthservices.ca
• Lori Rutman, Seattle Children’s Hospital, Seattle, Washington, USA – Lori.Rutman@seattlechildrens.org
• Brad Sobolewski, Cincinnati Children’s Hospital, Cincinnati, Ohio, USA – Brad.Sobolewski@cchmc.org @PEMTweets

Presentation Slides

PAS Poster

DRAFT: Choosing Wisely: Labs for psychiatric clearance

Best Practices and tips for each Choosing Wisely recommendation

Do not obtain radiographs in children with bronchiolitis, croup, asthma, or first-time wheezing

Respiratory illnesses are among the most common reasons for pediatric emergency department (ED) visits, with wheezing being a frequently encountered clinical finding. For children presenting with first-time wheezing or with typical findings of asthma, bronchiolitis, or croup, radiographs rarely yield important positive findings and expose patients to radiation, increased cost of care, and prolonged ED length of stay. National and international guidelines emphasize the value of the history and physical examination in making an accurate diagnosis and excluding serious underlying pathology. Radiography performed in the absence of significant findings has been shown to be associated with overuse of antibiotics. Radiographs should not be routinely obtained in these situations unless findings such as significant hypoxia, focal abnormalities, prolonged course of illness, or severe distress are present. If wheezing is occurring without a clear atopic etiology or without upper respiratory tract infection symptoms (eg, rhinorrhea, nasal congestion, and/or fever), appropriate diagnostic imaging should be considered on a case-by-case basis.

References

Ralston SL, Lieberthal AS, Meissner HC, et al. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics. 2014;134(5):e1474-e1502. DOI: https://doi.org/10.1542/peds.2014-2742

Trottier ED, Chan K, Allain D, Chauvin-Kimoff L. Managing an acute asthma exacerbation in children. Paediatr Child Health. 2021;26(7):438-439. DOI: 10.1093/pch/pxab058

Shah SN, Bachur RG, Simel DL, Neuman MI. Does this child have pneumonia? The rational clinical examination systematic review. JAMA. 2017;318(5):462-471. DOI: 10.1001/jama.2017.9039

Schuh S, Lalani A, Allen U, et al. Evaluation of the utility of radiography in acute bronchiolitis. J Pediatr. 2007;150(4):429-433. DOI: 10.1016/j.jpeds.2007.01.005

National Heart, Lung, and Blood Institute. Expert Panel Report 4: Guidelines for the Diagnosis and Management of Asthma; National Asthma Education and Prevention Program, Third Expert Panel on the Diagnosis and Management of Asthma. Bethesda, MD: National Heart, Lung, and Blood Institute; 2007:391

Do not obtain screening laboratory tests in the medical clearance process of pediatric patients who require inpatient psychiatric admission unless clinically indicated

The incidence of mental health problems in children has increased in the last two decades, with suicide surpassing homicide as the second leading cause of death in teenagers. Most children with acute mental health issues do not have underlying medical etiologies for these symptoms. A large body of evidence, in both adults and children, has shown that routine laboratory testing without clinical indication is unnecessary and adds to health care costs. Any diagnostic testing should be based on a thorough history and physical examination. Universal requirements for routine testing should be abandoned.

References

Thrasher TW, Rolli M, Redwood RS, et al. ‘Medical clearance’ of patients with acute mental health needs in the emergency department: a literature review and practice recommendations. WMJ. 2019;118(4):156-163

Donofrio JJ, Horeczko T, Kaji A, Santillanes G, Claudius I. Most routine laboratory testing of pediatric psychiatric patients in the emergency department is not medically necessary. Health Aff (Millwood). 2015;34(5):812-818

Chun TH. Medical clearance: time for this dinosaur to go extinct. Ann Emerg Med. 2014;63(6):676-677

Donofrio JJ, Santillanes G, McCammack BD, et al. Clinical utility of screening laboratory tests in pediatric psychiatric patients presenting to the emergency department for medical clearance. Ann Emerg Med. 2014;63(6):666-675.e663.

Santillanes G, Donofrio JJ, Lam CN, et al. Is medical clearance necessary for pediatric psychiatric patients? J Emerg Med. 2014;46(6):800-807

Santiago LI, Tunik MG, Foltin GL, Mojica MA. Children requiring psychiatric consultation in the pediatric emergency department—epidemiology, resource utilization, and complications. Pediatr Emerg Care. 2006;22(2):85-89

Do not order laboratory testing or a CT scan of the head for a patient with an unprovoked, generalized seizure or a simple febrile seizure who has returned to baseline mental status

Children presenting with unprovoked, generalized seizures or simple febrile seizures who return to their baseline mental status rarely have blood test or CT scan findings that change acute management. CT scans are associated with radiation-related risk of cancer, increased cost of care, and added risk if sedation is required to complete the scan. A head CT scan may be indicated in patients with a new focal seizure, new focal neurologic findings, or high-risk medical history (such as neoplasm, stroke, coagulopathy, sickle cell disease, age <6 months).

References

Hirtz D, Ashwal S, Berg A, et al. Practice parameter: Evaluating a first nonfebrile seizure in children. Report of the Quality Standards Subcommittee of the American Academy of Neurology, the Child Neurology Society, and the American Epilepsy Society. Neurology. 2000; 55(5):616-623. Reaffirmed October 17, 2020

Riviello JJ Jr, Ashwal S, Hirtz D, et al; American Academy of Neurology Subcommittee; Practice Committee of the Child Neurology Society. Practice parameter: Diagnostic assessment of the child with status epilepticus (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2006;67(9):1542-1550

McKenzie KC, Hahn CD, Friedman JN; Canadian Paediatric Society, Acute Care Committee. Emergency management of the paediatric patient with convulsive status epilepticus. Paediatr Child Health. 2021;26(1):50-57

American Academy of Pediatrics, Subcommittee on Febrile Seizures. Neurodiagnostic evaluation of the children with a simple febrile seizure. Pediatrics. 2011;127(2):389-394. DOI: https://doi.org/10.1542/peds.2010-3318

Do not obtain abdominal radiographs for suspected constipation

Functional constipation and nonspecific, generalized abdominal pain are common presenting complaints for children in emergency departments. Constipation is a clinical diagnosis and does not require testing, yet many of these children receive an abdominal radiograph. However, subjectivity and lack of standardization result in poor sensitivity and specificity of abdominal radiographs to diagnose constipation. Use of abdominal radiographs to diagnose constipation has been associated with increased diagnostic error. Clinical guidelines recommend against obtaining routine abdominal radiographs in patients with clinical diagnosis of functional constipation. The diagnosis of constipation or fecal impaction should be made primarily by history and physical examination, augmented by a digital rectal examination when indicated.

References

Freedman SB, Rodean J, Hall M, et al. Delayed diagnoses in children with constipation: multicenter retrospective cohort study. J Pediatr. 2017;186:87-94.e16. DOI: https://doi.org/10.1016/j.jpeds.2017.03.061

Pensabene L, Buonomo C, Fishman L, Chitkara D, Nurko S. Lack of utility of abdominal x-rays in the evaluation of children with constipation: Comparison of different scoring methods. J Pediatr

Gastroenterol Nutr. 2010;51(2):155-159. DOI: https://doi.org/10.1097/MPG.0b013e3181cb4309
Berger MY, Tabbers MM, Kurver MJ, Boluyt N, Benninga MA. Value of abdominal radiography, colonic transit time, and rectal ultrasound scanning in the diagnosis of idiopathic constipation in children: a systematic review. J Pediatr. 2012;161(1):44–50.e502. DOI: https://doi.org/10.1016/j.jpeds.2011.12.045

Tabbers MM, DiLorenzo C, Berger MY, et al. Evaluation and treatment of functional constipation in infants and children: Evidence-based recommendations from ESPGHAN and NASPGHAN.

J Pediatr Gastroenterol Nutr. 2014;58(2):258-274. DOI: https://doi.org/10.1097/mpg.0000000000000266
Kearney R, Edwards T, Braford M, Klein E. Emergency provider use of plain radiographs in the evaluation of pediatric constipation. Pediatr Emerg Care. 2019;35(9):624-629. DOI: 10.1097/ PEC.0000000000001549

Freedman SB, Thull-Freedman J, Manson D, et al. Pediatric abdominal radiograph use, constipation, and significant misdiagnoses. J Pediatr. 2014;164(1):83-88.e2

Do not obtain comprehensive viral panel testing for patients who have suspected respiratory viral illnesses

Viral infections occur frequently in children and are a common reason to seek medical care. The diagnosis of a viral illness is made clinically and usually does not require confirmatory testing. Additionally, there is a lack of consistent evidence to demonstrate the impact of comprehensive viral panel (i.e., panels simultaneously testing for 8–20+ viruses) results on clinical outcomes or management, especially in emergency department settings. Hence, most national and international clinical practice guidelines do not recommend their routine use. Additionally, some viral tests are quite expensive, and obtaining nasopharyngeal swab specimens can be uncomfortable for children. Comprehensive viral panel testing can be considered in high-risk patients (eg, immunocompromised) or in situations in which the results will directly influence treatment decisions such as the need for antibiotics, performance of additional tests, or hospitalization. Testing for specific viruses might be indicated if the results of the testing may alter treatment plans (e.g., antivirals for influenza) or public health recommendations (e.g., isolation for SARS-CoV-2). For more specific recommendations related to diagnosis and management of SARS-CoV-2, please see www.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/).

References

Gill, PJ, Richardson, SE, Ostrow O. Testing for respiratory viruses in children: to swab or not to swab. JAMA Pediatr. 2017;171(8):798-804

Noël KC, Fontela PS, Winters N, et al. The clinical utility of respiratory viral testing in hospitalized children: a meta-analysis. Hosp Pediatr. 2019;9(7):483-494

Parikh K, Hall M, Mittal V, et al. Establishing benchmarks for the hospitalized care of children with asthma, bronchiolitis, and pneumonia. Pediatrics. 2014;134(3):555-562

Innis K, Hasson D, Bodilly L, et al. Do I need proof of the culprit? Decreasing respiratory viral testing in critically ill patients. Hosp Pediatr. 2021;11(1):e1-e5

Bonus! Photos from PAS 2023