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Information for health-care providers

The implementation of our recommendation lists has provided an opportunity for meaningful discussion, education, and quality initiatives around the recommendations and has subsequently generated measurable improvements in multiple areas in the hospital. Outside of SickKids, our recommendations have been disseminated nationally and internationally through multiple channels including presentations and publications, and being featured by CPS, PAS and Choosing Wisely Canada to help educate the greater paediatric provider population. Our methodologies for implementation have also been shared with other paediatric institutions to aid in the conceptualization and implementation of recommendations of their own.

Although the implementation strategies for our Choosing Wisely recommendations varied, a number of enablers for success have been established. These include the assignment of a physician champion with multidisciplinary team involvement; the clear support of hospital leaders; the implementation of educational initiatives to support the recommendations; the availability of data to measure impact; and the ability to implement systematic changes to the process of ordering tests. It is essential to ensure that the high-quality outcomes derived through Choosing Wisely are achieved without any unintended consequences. Throughout implementation, potential negative outcomes resulting from our recommendations are being measured and no significant changes have been noted to date.

Learn more about some of our ongoing implementation activities below:

Recommendation: ​​​Don't use routine radiography in children who present with acute ankle injuries and meet criteria for a low-risk examination.

In North America, approximately 2 million children present to emergency departments annually with ankle injuries; about 12 per cent demonstrate fractures on plain films. A paediatric clinical decision rule (Low-Risk Ankle Rule) has been developed, validated and demonstrated a safe reduction in unnecessary radiographs by up to 60 per cent. Implementing this rule reduces unnecessary radiation exposure and saves health care resources. 

Background: Baseline audits completed in the Emergency Department (ED) found that 90 per cent of children between the ages of three to 16 years of age received radiographs for acute ankle injuries.

Implementation Plan: Following the audit, a number of implementation strategies were developed to enforce use of the Low-Risk Ankle Rule including education dissemination, visual cues such as posters, modified diagnostic imaging requisition and a clinical decision rule within Epic.

Results: Through our interventions there has been a significant reduction in the proportion of patients receiving ankle x-rays without an increase in Emergency Department length-of-stay, return visits and need for orthopedic follow up.

Read more here.

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Recommendation: Don't automatically give IVIG as first-line treatment for children with newly diagnosed, typical ITP

Management choices for children with newly diagnosed, typical ITP include observation (when the bleeding is mild), prednisone, or IVIG. Each option has risks and benefits; ideally these can be discussed with families and their preferences accounted for. There is no evidence of a relationship between any of these initial therapies and the subsequent development of severe bleeding. Prior to choosing IVIG, consideration should be given to its expense, its requirement for a day-hospital or overnight admission, and its side effect profile that frequently includes aseptic meningitis.

Background:​ From 2007 to 2009, a QI team developed a cross-sectional study of management of newly diagnosed, typical ITP at SickKids to assess the IVIG treatment rate. 

Implementation Plan​​: From 2013 to 2015, the team struck a collaborative interdisciplinary working group and implemented a QI bundle to decrease the use of hospital resources (including use of IVIG) while optimizing family satisfaction. The bundle comprised development of a patient information sheet; development of an evidence-informed, consensus-based protocol; and promotion of shared decision-making via stakeholder engagement and education.

Strategies include regular communication with stakeholders (Emergency Department (ED), Haematology, Paediatric Medicine); electronic availability of the protocol; and accessibility of the Paediatric Medicine day hospital ("ACE space") to care for this population as an alternative to inpatient admission.

Results: Through Choosing Wisely, the rate of IVIG use has decreased from 88 per cent to 55 per cent by not automatically giving IVIG as first-line treatment for children with newly diagnosed, typical ITP. 

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Recommendation: Don't routinely order nasopharyngeal (NP) testing for typical respiratory viruses unless results are likely to impact management.

Respiratory viral infections frequently occur in children and are a common reason to seek medical care. The diagnosis is made clinically and usually does not require confirmatory testing. Nasopharyngeal (NP) testing is uncomfortable for children and the results frequently do not impact their medical management. Therefore, NP testing should only be considered in high-risk patients where results will influence treatment decisions such as the need for antibiotics, performance of additional tests, or hospitalization. Reducing routine respiratory viral testing promotes high-value care and allows for more effective allocation of health care resources.​

Background: In 2014, almost 6,000 NP swabs were completed on children at SickKids. Of the 2,600 NP swabs ordered from the Emergency Department (ED) alone, approximately 63 per cent of these swabs were completed on children who were discharged home and these results were generally never followed up on by a provider or relayed to the family. 

Implementation Plan: A multi-divisional expert panel reviewed published guidelines and formulated the Choosing Wisely Respiratory Virus Pathway that was launched in January 2016, with a multi-faceted educational campaign. By reducing NP swab testing, resources were allocated towards two new tests for the hospital that promote high-quality care. The first was a Point of Care Rapid Influenza test that provides immediate results for children presenting with flu-like symptoms where oseltamivir treatment may be indicated or where an immediate positive influenza result will impact further management decisions like antibiotics, imaging, or even admission. The second test adopted was a new and improved Respiratory Virus Multiplex PCR test. This test has a much higher sensitivity when specifically compared with the older DFA test and can detect 16 respiratory viruses in children who will benefit from the test, like those admitted to our ICUs. The electronic order set was modified by introducing a force function that requires users to select an appropriate indication for testing from the pathway. As a hard-stop, the rapid influenza test can only be ordered for inpatients with Microbiologist approval.

Results: Respiratory virus testing decreased by over 80 per cent in the ED. When factoring in the new rapid influenza test, there was still a 51 per cent and 27 per cent decrease in total testing in the ED and Pediatric Medicine respectively, compared with 2014. ​

Read more here.

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Recommendation: ​​​Don't routinely order a CT abdomen/pelvis for paediatric trauma patients deemeed low risk by established decision rules for clinically significant intra-abdominal injury.

CT imaging among paediatric trauma patients is often overused leading to increased risk from ionizing radiation, increased need for procedural sedation, and increased cost to the health care system. For paediatric trauma, abdominal/pelvic CT imaging is commonly ordered because of a concerning mechanism of injury, which has not on its own been demonstrated to correlate with intra-abdominal injury. Rates of CT abdominal/pelvic imaging can be safely reduced by utilizing evidence-based clinical decision rules, of which two exist to guide diagnostic imaging in this patient population. These two distinct clinical decision rules, developed through two separate clinical research networks (PECARN - Pediatric Emergency Care Applied Research Network, and PedSRC - Pediatric Surgery Research Collaborative​), have both demonstrated abdominal/pelvic CT scan rates of 45-46% for all pediatric trauma activation patients of which 17-25% of children fall into a very low risk criteria, where CT imaging was not indicated. 

Background: At SickKids, a team has identified the problem of overuse of CT imaging as a screen for abdominal, head and cervical spine injuries, particularly in low-risk patients through concerns brought forth from informal observations, email concerns, chart reviews and M&M reports. At our institution many CT scans are obtained on the basis of mechanism of injury alone, which has not held up as a valid predictor of clinically important injury in pediatric trauma.

A preliminary audit of paediatric trauma registry patients was performed to determine appropriateness of CT imaging for head, spine, chest, and abdomen/pelvis over a 6 year period (2010-2016).   On average, 41.5% (31.7 - 55.1) of paediatric trauma patients received abdominal/pelvic CT scans, of which 27.9% (20.5 - 32.8) had an injury severity score (ISS) ≤​8, suggesting many of these children may not have merited abdominal/pelvic imaging.  In 2016-2017 rates went up significantly with 55.1% of children having an abdominal/pelvic imaging and 32.0% had an ISS ≤8.  The team will perform a retrospective chart review to fully understand the indications for imaging and the rates of positive studies.

Implementation Plan: Reduction in unnecessary CT imaging rates were achieved through implementation of a standardized evidence-based clinical guideline within the Hospital, which was developed and disseminated amongst all trauma providers.  Additionally, modifications to the diagnostic imaging requisitions specifically for trauma, forcing ordering clinicians to choose an indication were developed.  Further, Choosing Wisely educational outreach sessions specifically for trauma providers were executed, with close collaboration amongst Diagnostic Imaging, General Surgery and Emergency Medicine.  Rates of abdominal/pelvic imaging are collected prospectively with chart reviews done to determine if and when indications are followed. 

Results: To date, mean abdominal/pelvic imaging of very low risk paediatric trauma patients has dropped from 26.8% to 8.6%, with a statistically and clinically significant absolute reduction of 18.2%.

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Recommendation: ​​​Don't empirically start antibiotics for children over three months of age with low risk of urinary tract infection (UTI) without evidence of nitrites or significant pyuria on urine dipstick.  Do stop antibiotics if the urine culture is negative.

Urinary tract infections are a common infection in children and a leading cause for acute care visits in pediatrics. The diagnosis is often made on the basis of clinical symptoms, pyuria on dipstick analysis and confirmed by a positive urine culture. Since urine culture results are not immediately available, clinicians often empirically prescribe antibiotics to patients for suspected UTIs. However, since UTI symptoms are often nonspecific and urinalysis has varying sensitivity and specificity, children over three months of age that are low risk should not receive empiric antibiotics without evidence of nitrites or significant pyuria on urine dipstick. Empiric antibiotics should be discontinued if final urine culture results are negative.​

Background: During a three month period in 2016 at SickKids, 184 low-risk patients were diagnosed with a UTI in the Emergency Department (ED).  Approximately​ 47% of these patients received antibiotics despite negative urine cultures and none of these patients received notification to stop.  This practice led to 652 unnecessary antibiotic days for these patients.

Implementation Plan: To promote high-value care and reduce unnecessary exposure to antibiotics, a multifaceted implementation strategy was developed involving key hospital stakeholders in Emergency Medicine, Infectious Disease, Microbiology and Urology. In order to improve the accuracy of an empiric UTI diagnosis, a guided, evidence based algorithm was created based on urinalysis results to determine whether an empiric antibiotic treatment is recommended while pending urine culture results (Figure 2).  Additio​nally, a standard antibiotic discontinuation protocol for patients with negative urine cultures is being implemented in the ED. A strategy to standardize antibiotic prescription duration will also be instituted along with a targeted educational campaign to promote the initiative throughout the hospital.

Results: The introduction of the CW UTI algorithm has resulted in a 40% decrease in inappropriate UTI diagnosis and 770 unnecessary antibiotic days have been saved.

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Recommendation: ​​​Don't routinely continue antibiotics for surgical site infection prevention after the patient has left the operating room.

Surgical antibiotic prophylaxis (SAP) given immediately prior to surgery has been shown to significantly decrease the risk of surgical site infection (SSI). However, prolonged use has not demonstrated benefit over the single dose of antibiotics preoperatively. As such, prolonged SAP results in unnecessary antibiotic exposure which may contribute to the development of resistant organisms.  This does not apply to situations where there is infection that requires antibiotic treatment.  ​

Background: In 2016, the World Health Organization (WHO) published comprehensive recommendations on strategies to prevent SSIs. As part of this, a systematic review was conducted comparing single dose SAP (no postoperative dose) with any prolonged postoperative prophylaxis. There was moderate quality of evidence from a high number of RCTs (44 studies) that prolonged SAP postoperatively had no benefit in reducing SSI when compared to a single preoperative dose (OR 0.89, 95%CI 0.77, 1.03, p=0.12). As such, the WHO recommends against any SAP administration after completion of the operation for the purpose of preventing SSI.  

An audit of postoperative antibiotic use was conducted in 2015 to assess compliance with our current SickKids guidelines, which are consistent with the WHO recommendations. Overall adherence to the SickKids Guidelines was 70%, with the highest adherence being 100% and the lowest 0% depending on the surgical division. Some patients or prescribers continued antibiotics because of the presence of indwelling drains/catheters, a practice that is currently not recommended.

Implementation Plan: The primary method of reducing postoperative prophylaxis is through education and the engagement of clinical pharmacists and nurse practitioners on surgical services. The team meets with individual Divisions to review current formulary recommendations and strategize on methods to improve adherence within their division.

Results: To date, monthly random samples of approximately 10 per cent of surgical cases from seven surgical services are reviewed to assess adherence to SickKids formulary guidelines. Through this audit and feedback strategy as well as education, stakeholder engagement and order-set revisions in Epic, adherence has improved and the target of 85 per cent has been reached.