Using Quality Improvement to Change Testing Practices for Community-acquired Pneumonia

BACKGROUND: National guidelines for pediatric community-acquired pneumonia (CAP) contain recommendations regarding diagnostic testing including chest radiographs (CXRs), complete blood counts (CBCs), and blood cultures. Local data indicated that our institution was not delivering care at standards outlined by these guidelines. This project aimed to decrease CXRs for children with CAP discharged from the emergency department (ED) by 10% and decrease CBCs and blood cultures for patients hospitalized with uncomplicated CAP by 20% within 1 year. METHODS: This single-site quality improvement initiative targeted otherwise healthy children 3 months to 18 years who presented to the ED with uncomplicated CAP at a free-standing academic children’s hospital. A quality improvement team performed a series of interventions including guideline implementation, data sharing, and annual education. Process measures included CXR, CBC, and blood culture rates. Balancing measures included the number of patients diagnosed with CAP, the frequency of antibiotic use, length of stay, and ED and hospital return rates. The team used statistical process control charts to plot measures. RESULTS: There was special cause improvement with a desirable downward shift in testing that correlated with the project’s interventions. The percentage of CXRs for discharged patients decreased from 79% to 57%. CBCs and blood cultures for hospitalized patients decreased from 30% to 19% and 24% to 14%, respectively. Balancing measures remained unchanged. CONCLUSIONS: We used elements of quality improvement methodology to reduce testing for uncomplicated CAP without impacting the number of patients diagnosed with CAP, the frequency of antibiotic use, length of stay, and reutilization rates.