Reducing Streptococcal Testing in Patients <3 Years Old in an Emergency Department

Pediatrics. 2019 Oct;144(4):e20190174. doi: 10.1542/peds.2019-0174. Epub 2019 Sep 11.


Background: Although pharyngitis is common, group A Streptococcus is an uncommon etiology, and sequelae are rare in patients <3 years old. Inappropriate testing leads to increased cost of health care and unnecessary exposure to antibiotics. Rapid streptococcal tests (RSTs) for group A Streptococcus pharyngitis are not routinely indicated in this age group. At our urban, tertiary pediatric emergency department (ED), on average, 20 RSTs were performed each month for patients <3 years of age. Our objective was to reduce RSTs in the ED in patients aged <3 years by 50% in 18 months.

Methods: We initiated this project in October 2016 at an urban, tertiary pediatric ED. We surveyed pertinent multidisciplinary stakeholders to identify factors leading to RSTs in children <3 years of age. We conducted multiple interventions and collected weekly data on the number of RSTs in children aged <3 years (outcome measure) and the number of family complaints and return visits for complications of pharyngitis (balancing measure). We used statistical process control for analysis.

Results: The mean number of RSTs ordered per month in patients aged <3 years declined by 52% in 10 months. The majority of tests during the study phase were ordered by nurse practitioners (62%) for patients aged 25 to 36 months (66%). There has been 1 family grievance and no patient complications attributable to the project.

Conclusions: Our interventions led to a successful and sustained reduction of RSTs in patients aged <3 years. A local clinical practice guideline was developed, and the project was expanded to other acute care settings.

MeSH terms

  • Child, Preschool
  • Decision Support Systems, Clinical
  • Electronic Health Records
  • Emergency Service, Hospital*
  • Female
  • Humans
  • Inservice Training
  • Male
  • Microbial Sensitivity Tests / statistics & numerical data*
  • Missouri
  • Pharyngitis / microbiology*
  • Streptococcal Infections / diagnosis*
  • Streptococcus pyogenes / isolation & purification
  • Unnecessary Procedures*