P2.D077: Choosing Wisely: Reducing Inappropriate Viral Testing Within the Pediatric Emergency Department

Purpose/Objectives: As part of the Choosing Wisely Campaign aimed at reducing unnecessary healthcare services and improving patient outcomes, the AAP Section on Emergency Medicine published “5 Things Physicians and Patients should Question in the Practice of Emergency Medicine” in 2022. The fifth topic recommends reserving comprehensive viral panel testing for high-risk patients or situations where results will impact treatment decisions or public health recommendations.

In the year prior to this QI initiative, the Phoenix Children’s Emergency Department RPP’s were ordered at 9% percentage of total ED visits resulting in $970,000 in testing costs. A random chart review of 328 patient charts showed that 50% percent of these were not clinically indicated. This QI project aimed to reduce inappropriate ordering of RPPs within our Pediatric ED from 50% to 40% over 6 months. Our secondary aim was to decrease the percentage of ED visits with RPPs ordered from 11.5% to 9% over the same 6-month time frame.

Design/Methods: We performed two Plan-Do-See-Act (PDSA) cycles. Our first PDSA cycle involved creating an ED guideline on five indications for ordering an RPP, corresponding with an educational rollout to our ED providers. Our second PDSA cycle was tiered by implementing a Quad (Influenza/Covid-19/RSV) PCR as a testing alternative and creating an ED viral testing order set with a required indication click box before ordering the RPP.

Our primary outcome looking at inappropriate RPP order use was measured by performing chart reviews looking at clinical appropriateness on RPPs ordered in the ED and pulling this information from the RPP order set once it rolled out. Our secondary outcome was evaluated by monitoring percentage of ED visits with an RPP order. Our balancing metric was to monitor percentage of viral testing orders that were RPPs compared to rapid flu and Quad PCRs.

Results: In the respiratory season the year prior to our quality initiative, 11.5% of all ED visits had an RPP ordered. Fifty percent were deemed not clinically indicated. The rate of inappropriate tests decreased from 50% to 28.5% after PDSA cycle 1 and maintained at 27% after PDSA cycle 2. Using only respiratory season timeframe data, the percent of ED visits with an RPP order decreased from 11.5% to 8.0% after PDSA cycle 1 and to 6.5% after PDSA cycle 2.

Over time, the trend of visits receiving rapid flu or quad PCR grew over time, with RPPs becoming less prevalent after our QI initiative began.

Conclusion/Discussion: By implementing a viral testing guideline and introducing a more focused viral panel with an order set requiring clinical indication, we reduced the amount of unnecessary RPP’s at our institution by 46% over the past 6 months. We also reduced the percentage of ED visits receiving an RPP test by 43%.