P2.279: Improving Imaging Stewardship in Pediatric Bronchiolitis: A Quality Improvement Approach

Purpose/Objectives: Chest radiographs (CXRs) are frequently overused in infants with bronchiolitis, despite the American Academy of Pediatrics’ Choosing Wisely guidelines advising against routine imaging in uncomplicated cases. Overuse of CXRs can contribute to unnecessary healthcare costs, patient exposure to ionizing radiation, and potentially lead to inappropriate antibiotic use. This quality improvement (QI) initiative aimed to reduce the rate of CXR use in low-risk bronchiolitis encounters in a pediatric emergency department (ED) from a historical average of 34% to 17% within nine months.

Design/Methods: This QI initiative was conducted at a freestanding, tertiary-care children’s hospital using Plan-Do-Study-Act (PDSA) cycles. Low-risk bronchiolitis was defined as infants aged 1–24 months discharged with a diagnosis code of acute bronchiolitis, excluding those with ICU admission, complex chronic conditions, ESI level 1 presentations, or concurrent diagnoses of asthma, pneumonia, or croup.
A multidisciplinary team—including physicians, advanced practice providers, nurses, utilization management staff, and family council members—identified key drivers of overuse: lack of standardized care pathways, variability in provider practices, limited data feedback, and family expectations. Interventions included provider education, updated clinical pathways, individualized feedback, public anonymized peer comparison via bubble and pareto charts, and family perspective surveys. Data were reviewed biweekly using the hospital’s quality dashboard.
The primary outcome was the percentage of low-risk bronchiolitis visits resulting in a CXR, displayed as a centerline on statistical process control charts. Balancing measures included ED revisit rates and subsequent hospital admissions. Fisher’s exact test was used for balancing measure comparisons.

Results: During the four-month intervention period, 729 low-risk bronchiolitis encounters were recorded, with 138 CXRs obtained. Baseline CXR utilization averaged 33.1% in the three months prior to the intervention. Within one month of implementing the first PDSA cycle, the centerline dropped to 19.6%, despite a seasonal increase in bronchiolitis volumes. After data transparency and provider feedback efforts, the centerline further decreased to 10.2%.
ED revisit rates before and during the intervention showed no significant difference (26.5% vs. 16.7%; p = 0.27). Among revisits, admission rates were also not significantly different (50.0% vs. 44.4%; p = 1.00). No acute abnormalities were identified on the only CXR obtained during revisit encounters in the QI period.

Conclusion/Discussion: A targeted, multidisciplinary QI initiative led to a significant and sustained reduction in CXR use for infants with low-risk bronchiolitis, without compromising patient safety. Key strategies included structured education, data feedback, and transparency. Future efforts will include EMR-based decision support, family education materials, and ongoing evaluation of provider practices.