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Information for health-care providers

The implementation of our 2016 list 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 CAPHC, 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:

  • Education dissemination: A brief presentation was prepared and disseminated to all physicians to educate them on the Low-Risk Ankle Rule. Presentations were also given to the nurses so that they also understood the decision rule and why patients may not be getting x-rays.
  • Posters: The team has placed posters in areas of the ED where ankle injuries are frequently assessed and managed. The posters include the decision tree that includes the rule and management associated with different outcomes.
  • Modified diagnostic imaging requisition:  The x-ray requisition has been modified to encourage clinicians to use the Low-Risk Ankle Rule prior to finalizing decisions for ordering x-rays for children with acute ankle injuries. This was done in collaboration with the Diagnostic Imaging department.  Technicians will also be involved in quality checking how often the rule was considered prior to doing ankle radiographs.
  • Clinical Decision Rule within Epic: With the launch of Epic in June 2018 the team will be leveraging technology to have clinicians document the Low-Risk Ankle Rule and provide clinical decision support to guide imaging.

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.

Figure 1: The proportion of patients presenting to SickKids ED with acute ankle injuries who received ankle x-rays.

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. 

Figure 2: Decrease in LOS for newly diagnosed, typical ITP patients as a results of the intervention.

Choosing Wisely has lent importance to this topic, and provided context in which we are promoting and monitoring ongoing quality improvement. Monitoring is achieved with quarterly data (calendar year), beginning January 2015. Data captured are those discharged from the ED (NACRS), from the Paediatric Medicine Inpatient Unit (DAD), and from the "ACE space" (Paediatric Medicine day hospital) (ACE data collection).

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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: In the first year of implementation, 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. ​

Figure 3: The decrease in ED respiratory multiplex testing rates since 2014. 

Figure 4: A reduction in routine use of respiratory viral testing has also been noted in the General Paediatrics.

Read more here.

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