P2.291: Swabbing Sensibly: Smarter Flu Testing for Better Care and Lower Costs

Purpose/Objectives: Flu testing is recommended for high-risk patients (age < 2 years or with chronic conditions) who may benefit from oseltamivir treatment during viral season (Oct – March). However, in low-risk patients the side effects of oseltamivir may outweigh the benefits. During the COVID-19 pandemic (when COVID testing was coupled in a “Quad” with flu testing), testing rates of ED low-risk patients rose from peak of 9% pre-pandemic to 46% in 2022. Despite loosening of COVID-19 testing guidelines, rates haven’t decreased to pre-pandemic levels and many tests sent were contradictory to CHOP’s clinical pathway guidance. With each Quad test charging $2,103, unnecessary testing generates projected millions of dollars in cost without impacting management.

This Quality Improvement project aimed to decrease flu testing rates from 20% to 5% between FY24 and FY25 for discharged low-risk patients presenting to the CHOP EDs during flu season inclusive of race, ethnicity, and preferred language.

Design/Methods: A multiprong approach was used to raise awareness about unnecessary testing in the ED. Prior to the FY25 flu season, the pathway and project objectives were reviewed with the division of Emergency Medicine. Talking points were disseminated to support provider-caregiver communication regarding testing indications, consequences of unnecessary testing, and risk/benefit profile of oseltamivir. Nurse standing orders criteria were refined to facilitate clinician-driven decision-making. School note templates were developed to support families desiring testing for external requirements. Patient-facing screensavers were created for waiting areas and patient rooms to educate families on testing recommendations. A Qliksense database was created to track testing rates, pathway adherence and approximate testing charges. Biweekly assessments of testing patterns and reminders for testing indications were shared at division meetings.

Results: Pre-pandemic, unnecessary flu testing rates peaked at 9.3%. Post-pandemic (FY23), they peaked at an all-time high of 46.1%. Following changes to COVID-19 testing policies (FY24), rates declined but remained high at 22.9%. After PDSA cycles in October 2024, FY25 rates peaked at 16.6%. Nursing standing order testing remained stable, accounting for approximately 5% of tests in both FY24 and FY25. Estimated charge reduction from FY24 to FY25 was approximately $3.87 million.

Conclusion/Discussion: Despite a 6.3% reduction from FY24 to FY25, flu testing rates in discharged low-risk patients remain high. Providers and nurses responded positively to education. Nursing standing order testing rates remain unchanged, although these account for a small proportion of testing.

These findings underscore the need for continued diagnostic stewardship. Reducing unnecessary testing is critical to high value care and promotes more efficient resource allocation.

As a next step, the clinical pathway team plans to further investigate the impact of high flu testing rates, behaviors of ordering providers driving testing, and plan to develop the most efficient model for the next flu season.