Reducing Chest Radiographs in Bronchiolitis Through High-Reliability Interventions

Pediatrics. 2021 Sep;148(3):e2020014597. doi: 10.1542/peds.2020-014597. Epub 2021 Aug 3.


Background and objectives: Bronchiolitis is a leading cause of pediatric hospitalization in the United States, resulting in significant morbidity and health care resource use. Despite American Academy of Pediatrics recommendations against obtaining chest radiographs (CXRs) for bronchiolitis, variation in care continues. Historically, clinical practice guidelines and educational campaigns have had mixed success in reducing unnecessary CXR use. Our aim was to reduce CXR use for children <2 years with a primary diagnosis of bronchiolitis, regardless of emergency department (ED) disposition or preexisting conditions, from 42.1% to <15% of encounters by March 2020.

Methods: A multidisciplinary team was created at our institution in 2012 to standardize bronchiolitis care. Given success with higher reliability interventions in asthma, similar interventions affecting workflow were subsequently pursued with bronchiolitis, starting in 2017, by using quality improvement science methods. The primary outcome was the percent of bronchiolitis encounters with a CXR. The balancing measure was return visits within 72 hours to the ED. Statistical process control charts were used to monitor and analyze data obtained from an internally created dashboard.

Results: From 2012 to 2020, our hospital had 12 120 bronchiolitis encounters. Preimplementation baseline revealed a mean of 42.1% for CXR use. Low reliability interventions, like educational campaigns, resulted in unsustained effects on CXR use. Higher reliability interventions were associated with sustained reductions to 23.3% and 18.9% over the last 4 years. There was no change in ED return visits.

Conclusions: High-reliability workflow redesign was more effective in translating American Academy of Pediatrics recommendations into sustained practice than educational campaigns.

MeSH terms

  • Bronchiolitis / diagnosis*
  • Child, Preschool
  • Emergency Service, Hospital / statistics & numerical data
  • Hospitals, Pediatric
  • Humans
  • Medical Overuse / prevention & control*
  • Patient Care Team
  • Quality Improvement / organization & administration*
  • Radiography, Thoracic / statistics & numerical data*
  • Tennessee