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SickKids

Choosing Wisely at SickKids

It has been estimated that, in North America, 20-30% per cent of the tests and therapies currently requested and prescribed are likely unnecessary, add no value to care, and may even cause harm. That's why SickKids has participated in Choosing Wisely Canada, a campaign to help clinicians and patients engage in conversations about unnecessary tests and treatments, since 2016.

SickKids has produced a total of 15 recommendations that are specific to paediatric hospital patients. The recommendations developed are based on best-practices and evidence of overuse or potential harm to patients.

SickKids is the first paediatric hospital to be designated a Level 3 Choosing Wisely Canada Hospital for implementing at least 10 recommendations and demonstrating our deep commitment through organizational leadership, culture change and mentorship

Implementation toolkits

Image of front cover of toolkit document. The background is black with a white ankle x-ray and includes the title of the document "Say Nay to the X-Ray".

Say Nay to the X-ray

Choosing Wisely Canada mobilizes and supports clinicians and organizations committed to embedding campaign recommendations into practice. With their support, SickKids developed an evidence-based and easy to follow toolkit – “Say Nay to the X-ray” – which includes tools and methods to reduce unnecessary low-risk ankle imaging at paediatric emergency departments. The toolkit is available publicly to support quality improvement and decrease unnecessary tests and treatments in paediatric health care settings.

Download Toolkit (English) (PDF) Download Toolkit (French) (PDF)

Frequently asked questions for patients and families

As the Choosing Wisely movement in Canada had previously focused on adults without any formal recommendations for children (paediatrics), the goal of the Choosing Wisely initiative at SickKids is to encourage conversations about tests and treatments that may not be needed by creating recommendations that are specific to our young patient population and that resonate with paediatric care.

We will always continue to use appropriate tests for children who need them. The aim of Choosing Wisely is to reduce testing for children whose diagnosis and care will not be impacted by the results of tests.  Many conditions can be identified by a simple examination. While tests can confirm a diagnosis, many do not impact the care that is provided due to the long wait time for results and other factors.

All the tests on Choosing Wisely lists are safe for patients. However, they simply may not be necessary for as many patients as they are currently being used for. The idea with Choosing Wisely is for health-care providers to think more carefully about how they will use the information from a test, if at all. If it's not going to be used, better to avoid the test.

Choosing Wisely Canada recommends four questions to ask your health-care provider:

  1. Do I [does my child] really need this test, treatment or procedure?
  2. What are the downsides?
  3. Are there simpler, safer options?
  4. What happens if I [we] do nothing?

Information for health-care providers

Implementing our Choosing Wisely recommendations provides opportunities for meaningful discussion, education, and quality initiatives and has generated measurable improvements. Outside of SickKids, our recommendations have been disseminated nationally and internationally to help educate the greater paediatric provider population through presentations and publications, and being featured by Canadian Paediatric Society, Pediatric Academic Societies and Choosing Wisely Canada. Our methods for implementation have also been shared with other paediatric institutions to help them conceptualize and implement recommendations of their own.

Although the implementation strategies for our Choosing Wisely recommendations varied, we have identified a number of enablers for success. These include:

  • assigning a physician champion with multidisciplinary team involvement;
  • clear support of hospital leaders;
  • implementing educational initiatives to support the recommendations;
  • availability of data to measure impact;
  • ability to implement systematic changes to the process of ordering tests.

It is essential to ensure that high-quality outcomes derived through Choosing Wisely are achieved without any unintended consequences. Throughout implementation, we measure potential negative outcomes resulting from our recommendations and no significant changes have been noted to date.

Implementing SickKids recommendations

Respiratory viral infections frequently occur in children and are a common reason to seek medical care. The diagnosis is generally made clinically and usually does not require confirmatory testing for typical viruses. Nasopharyngeal (NP) sampling for a viral test is uncomfortable for children and the results frequently do not impact their medical management. Therefore, respiratory viral testing should only be considered when results will influence treatment decisions such as the need for antibiotics, performance of additional tests, hospitalization, or for infection control practices in pandemics. Reducing unnecessary 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, 63% of these swabs were completed on children who were discharged home and these results were generally never followed up by a provider or relayed to the family.

Implementation

A multi-divisional expert panel reviewed published guidelines and formulated the Choosing Wisely Respiratory Virus Pathway for the ED and General Paediatrics.  In January 2016, the Pathway was launched using a multi-faceted intervention strategy including force functions in our health information system, an educational campaign, and audit and feedback. By reducing unnecessary NP swab testing, resources were allocated towards two new tests 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 to our ED 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 was a new and improved Respiratory Virus Multiplex PCR test that can detect 16 respiratory viruses in children who will benefit from the test, like those admitted to our ICUs.

Results

Since 2016, the hospital has reduced the use of nasopharyngeal (NP) swab testing for typical respiratory viruses.  Significant gains have been made in the ED with a reduction in respiratory multiplex PCR testing of over 80%. With the introduction of the new rapid influenza test, viral respiratory testing still decreased greater than 50% in the ED. These gains have spread to the General Paediatrics units where NP testing decreased by 35%. These reductions have been sustained in all areas for over three years.

To learn more, read "Less is more: new review suggests paediatricians should think twice before routinely testing for respiratory viruses"

Previous guidelines recommended routine VCUG after first febrile urinary tract infections (UTI) in young children. However, a more recent body of research has not supported this practice. In addition VCUGs are uncomfortable, and expose children to ionizing radiation. Thus, most recent guidelines suggest that VCUG should be considered after febrile UTI only in select circumstances: for example, when the renal ultrasound is abnormal suggestive of higher grade reflux, or scarring; in atypical circumstances; or with recurrent UTI.

Background

From January 2014 to November 2015, an audit examined how frequently infants and children admitted to the General Pediatrics Inpatient Unit at SickKids for a UTI received a VCUG within three months of admission.  There were 149 admissions for UTI to the General Pediatrics Inpatient Unit during this period.  Within this patient population, the audit found that 29/149 (19.4%) received a VCUG. Only 2/29 (6.8%) VCUGs performed were not in accordance with guideline recommendations. This represents a 1.3% rate of inappropriate VCUG performance for all UTI admissions to the General Pediatric Inpatient Unit. For the 27 infants and children who had a VCUG appropriately performed, reasons included recurrent UTI, abnormal renal ultrasound, atypical/severe infection (sepsis, meningitis), genitourinary abnormality, and neurogenic bladder.​

Implementation

Given the very low rate of inappropriate VCUG performance SickKids Choosing Wisely did not embark on a major change plan. As part of the Choosing Wisely campaign, the team has used education directed at clinicians to sustain current performance. 

When children are in a stable phase of their acute respiratory hospitalization and do not require supplemental oxygen, observational research suggests that the use of continuous oxygen saturation monitoring leads to over-diagnosis and overtreatment of hypoxemia resulting in longer hospital stay.

Background

Random audits on the Paediatric Medicine Inpatient Unit began in February 2015 to examine what proportion of patients with bronchiolitis, asthma, and pneumonia who are not on supplemental oxygen are on continuous monitoring.  These audits occurred on specific days after morning medical patient rounds.  ​In 2015, when the initiative was first launched, it was found that for the month of February, 10/18 (56%) children and for the month of March 13/17 (76%) children audited who were not on supplemental oxygen were on continuous oxygen saturation monitoring.  This audit was repeated close to two years later, and in October of 2017, it was found that 16/22 (72%) of children audited who were not on supplemental oxygen were on continuous oxygen saturation monitoring. This demonstrated persistent use of continuous oxygen saturation monitoring despite education efforts between audits.

Implementation

Following the 2017 audit, a number of implementation strategies were developed including the development of a comprehensive education and awareness package targeted at medical (staff, fellows, residents), nursing and respiratory therapy staff; point-of-care initiatives in the form of visual cues such as sticker, notices, logos, posters, reminders placed directly on each communication board within patient rooms, as well at communal areas including workstations, pager chargers etc.; and audit and feedback occurring on the inpatient unit monthly.

Results

Prior to the initiative, the General Paediatrics wards were monitoring appropriately 60% of the time; after the first four weeks of interventions this increased to 78%.

Management choices for children with newly diagnosed, typical immune thrombocytopenia (ITP) include observation (when the bleeding is mild), prednisone, or intravenous immunoglobulin (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 quality improvement (QI) team developed a cross-sectional study of management of newly diagnosed, typical ITP at SickKids to assess the IVIG treatment rate.

Implementation

In 2013, the working group implemented a QI bundle to achieve their aim. The bundle included developing a patient information sheet; developing an evidence-informed, consensus-based protocol; and promoting shared decision-making via stakeholder engagement and education.  Strategies include regular communication with stakeholders (Emergency Medicine, Haematology, Paediatric Medicine); electronic availability of the protocol; and accessibility of the Paediatric Medicine day hospital to care for this population as an alternative to inpatient admission. Since 2017, refinements to the protocol have resulted in an increased number of patients being cared for via an outpatient pathway.

Results

The rate of IVIG use has decreased from 88% to 20% by not automatically giving IVIG as first-line treatment for children with newly diagnosed, typical ITP and sustained to date.

Read the CPS Practice Point

To learn more, read "SickKids study leads to new practice point for assessing management options for newly diagnosed, typical immune thrombocytopenia"

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

Background

Baseline audits completed in the ED found that 90% of children between the ages of three to 16 years of age received radiographs for acute ankle injuries.

Implementation

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 in our health information system.

Results

Since the initial audit routine radiography for children with low-risk acute ankle injuries has decrease from 90% to 53% in the ED.​

To learn more, read "Growth plate fractures in children’s ankle injuries are much rarer than previously thought"

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 randomized control trials (44 studies) that prolonged SAP postoperatively had no benefit in reducing SSI when compared to a single preoperative dose. 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

In 2019, SickKids targeted SAP after surgery by including the measurement of appropriateness on the hospital’s Key Performance Indicators. Appropriate use improved after meetings with specific surgeons and surgical groups; increasing awareness of existing guidelines with Choosing Wisely initiatives; and modification of guidelines to align with evidence-informed practices, consensus guidelines, and protocols.  Monthly audits of approximately 10% of surgical cases from seven surgical services were 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.

Results

The average appropriateness increased from the baseline of <75% to a year to date average of 82% with several months exceeding our 85% target. The ongoing focus on surgical antibiotic prophylaxis has sustained with the help of Choosing Wisely.

CT imaging among paediatric trauma patients is often overused leading to unnecessary exposure of children to ionizing radiation, procedural sedation, and increased cost to the health care system. Rates of CT abdominal/pelvic imaging in children 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 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 pediatric trauma activation patients, of which 17-25% of children were considered very low risk (VLR), with both rules demonstrating expected yields (or positive results) of only 0-0.1% for intra-abdominal injury (IAI) requiring intervention when imaging this VLR group of patients.

Background

At SickKids, a team identified the problem of overuse of abdominal/pelvic CT imaging, particularly in low-risk patients through concerns brought forth from informal observations, email concerns, chart reviews and M&M reports. It was found that many CT scans were being obtained on the basis of mechanism of injury alone, which is not a valid predictor of clinically important injury in pediatric trauma.

An initial 2016/17 registry audit demonstrated that 55% of trauma activations were receiving abdominal/pelvic CT scans (above published means of 45-46% and higher than all previous years locally); additionally 32% of these kids had an injury severity score of ≤ 8, suggesting many of these children did not have IAI, and this was a signal for further exploration. A comprehensive chart review was then done for that same fiscal year, similarly demonstrating an abdominal/pelvic CT rate of 51%, with 26.8% of these children considered very low risk for IAI by retrospective application of specified clinical decision rules.

Therefore a quality improvement initiative was developed that aimed to reduce abdominal/pelvic CT imaging in pediatric trauma patients at very low risk of IAI at the hospital by 20% over a six- month intervention period.

Implementation

Reduction in unnecessary CT imaging rates were achieved through implementation of a multifaceted approach involving hospital-wide education, audit and feedback, and system/process-based interventions with eight PDSA cycles using the Model for Improvement.

An evidence-based Trauma Diagnostic Imaging Algorithm, modeled on the National Institute of Clinical Excellence guidelines and incorporating both previously cited clinical decision rules was developed and ratified. Multi-modal educational dissemination occurred over the next few months in all relevant departments. “Just-in-time” clinical decision support, based upon iterative feedback, was then developed through use of a dedicated Trauma CT requisition with outlined indications required for ordering an abdominal/pelvic CT scan in trauma, and went through several PDSA cycles to ensure consistent and accurate use of the requisition. This project was fortunate to be chosen as a Choosing Wisely Intiative,and utilized that platform to broadly disseminate the recommendation to not CT image pediatric trauma patients at very low-risk of IAI. Rates of abdominal/pelvic imaging continue to be collected prospectively with chart reviews done to determine if and when indications are followed, with ongoing audit and feedback communication to both individual providers and group reminders about this initiative.

Results

To date, the mean abdominal/pelvic imaging rate of very low-risk paediatric trauma patients (primary outcome) has dropped from 26.8% to 6.1%, with a statistically and clinically significant absolute reduction of 20.1%. Overall rates of CT imaging have also dropped by approximately 20% in a significant and sustained fashion, and balancing measures have indicated no missed clinically significant injuries utilizing this approach.

Fever in children is a very common reason to seek medical attention and blood cultures are often drawn with bloodwork irrespective of the patient’s clinical presentation. Current rates of bacteremia in healthy vaccinated children are extremely low and contamination is common resulting in return visits, additional testing, and even hospital admissions and antibiotics. Blood cultures should only be sent when there is clinical suspicion for bacteremia. When a contaminated result is suspected or confirmed, a standardized approach should be utilized based on the gram stain and subsequent culture results and patient risk level to guide treatment decisions.

Background

The ED is the highest user of blood cultures in the hospital with 8% of all children visiting the ED getting a blood culture. Practice patterns often promote the overuse of ordering blood cultures in efforts to prevent a child from needing a second poke or to try to reduce diagnostic uncertainty. However, the true positive rate is 4.3% with a contamination rate of 2% resulting in repeat ED visits and even hospital admissions due to contaminated blood cultures.  Importantly, blood cultures are commonly drawn for certain focal infections such as pneumonia, skin and soft tissue infections (SSTIs), asthma, bronchiolitis as well as UTIs with evidence to show that the rates of positive blood cultures are low and do not change clinical management and outcomes.   

Implementation

A number of activities have been implemented to increase understanding of when blood cultures should be sent.  This includes the audit of blood cultures to better understand which patients are getting blood cultures; education to target awareness of known focal conditions that do not benefit from blood cultures; requiring a physician order for blood cultures to be processed; removing blood cultures from the Epic Quick List of investigations so that ordering requires a conscious decision. Future work will be on physician audit and feedback as well as developing a clinical decision rule for low-risk children with fever who do not need blood cultures.

Results

A retrospective chart review showed that 65% of blood cultures were drawn in low-risk patients, with over half of these patients being discharged home. Only 0.4% of these patients had positive blood cultures, none of which altered management. The majority of blood cultures drawn in low-risk patients (30%) were in patients with a diagnosis of fever; 10% were drawn in patients with a diagnosis of pneumonia where current practice guidelines do not support the use of routine blood cultures.  

Antibiotics are usually started when there is concern for possible infection. After two days, if culture results do not demonstrate a resistant organism, antibiotics should either be changed to a narrow-spectrum agent or discontinued if there is no longer evidence of infection. Minimizing patient exposure to broad spectrum antibiotics will help to decrease development of resistance to these agents and preserve their efficacy for future use.

Background

Targeted drug utilization evaluations of vancomycin and meropenem have shown that duration of treatment is a key factor contributing to inappropriate use. Sixty-three per cent of empiric courses of vancomycin were used for more than three days. At baseline, only 9% were found to be appropriate for definitive treatment of a proven pathogen. Additionally, 69% of patients started on meropenem empirically continued on treatment for an average of nine days, without documented evidence of infection requiring meropenem.

Implementation

Starting in June 2017, prolonged treatment (>72 hours) with vancomycin and meropenem became actively restricted by the Antimicrobial Stewardship Program (ASP) and the Infectious Disease (ID) service. This was done in accordance with the SickKids Restricted Drugs Policy. When either of these medications is ordered, the default stop date is set at 72 hours from the initial dose. Approval must be obtained to continue the medication beyond 72 hours. Each new order automatically generates a review by either the ASP or ID teams at 48 hours into therapy to review appropriateness and recommending continuing or changing therapy.  The team tracks the percentage of patients that receive > 72 hours of therapy with vancomycin or meropenem, and addresses individual units and services as needed.

Results

Comparing the six months prior to implementation of the stop date, to six months after implementation, the number of courses of meropenem that were >72 hours decreased from 65% to 55%. Prolonged courses of vancomycin decreased from 41% to 35%.

Urinary tract infections (UTIs) 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 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

To promote high-value care and reduce unnecessary exposure to antibiotics, a A multifaceted implementation strategy was developed involving key 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.  Additionally, a standard antibiotic discontinuation protocol for patients with negative urine cultures is beingwas implemented in the ED. A strategy to standardize antibiotic prescription duration will also be institutedwas also instituted in Epic along with a targeted educational campaign to promote the initiative throughout the hospital. In 2019, this initiative was added as a Key Performance Indicator for the Hospital.

Results

The introduction of the Choosing Wisely UTI algorithm has resulted in a 4240% decrease in inappropriate UTI diagnosis over the last two and a half years. With the implementation of a callback system in the ED, patient and families are now notified of the misdiagnoses 97% of the time leading toand over 70070 fewer unnecessary antibiotic days each year.

Most acute pain can be successfully treated with a multimodal therapeutic approach consisting of a combination of non-opioid pharmacotherapy (acetaminophen and/or nonsteroidal anti-inflammatory drugs [NSAIDS]), physical, and psychological interventions. Opioids should not be routinely prescribed for pain in children unless these strategies are therapeutically inadequate. When opioids are indicated, current opioid prescribing guidelines and standards recommend that opioids prescribed for acute pain for children who do not regularly take opioids should be prescribed for only short-term use at the lowest effective dose of morphine, the preferred first line opioid. Evidence suggests a duration of three days or less is often sufficient; more than seven days is rarely indicated and is associated with a risk of long-term opioid use. Prescribing physicians should provide patient- and caregiver-centred education about potential benefits and harms of opioid therapy, treatment options for the management of pain, and safe storage and disposal of unused medications, to allow them to make informed decisions about their care.

Background

The over-prescription of opioids has been implicated as a driver of the opioid epidemic. Youth opioid prescriptions have doubled in the past 10 years and young adults have the fastest growing rates of hospitalizations for opioid overdose. Persistent opioid use after episodes of acute pain or following surgery among adolescents and young adults may represent an important pathway to prescription opioid misuse. In response, the evidence-based Canadian Opioid Prescribing Guideline (2017) and Health Quality Ontario Quality Standards on Opioid Prescribing for Acute Pain (2018) have been developed to inform safe opioid prescribing among clinicians; however, these have not been mobilized consistently in clinical practice. Our aim is to to educate prescribing physicians, patients, and their caregivers to reduce harm and improve pediatric pain management by implementing and evaluating evidence-based quality standards related to opioid type, dose and duration in children with acute pain.

Implementation

In 2020, a quality improvement (QI) team at the SickKids Pain Centre developed a QI bundle to achieve their aim. The bundle included developing an evidence-based, consensus-based protocol; developing educational materials re: opioid prescribing for physicians; developing patient and caregiver education materials re: opioid benefits and harms; and promoting shared decision-making via stakeholder engagement and education. Strategies include regular communication with stakeholders (Medication Safety Committee, Patient Advisory Committee, Orthopedic Surgery and Plastic Surgery); electronic availability of the protocol; and measurement of outcome, process, and balancing measures based on Epic reports.

Results

Not yet available.

Thyroid function tests are among the most commonly ordered laboratory tests. Since thyroid-stimulating hormone (TSH) is sensitive to even small changes in free thyroxine (fT4) and triiodothyronine (T3) levels, current guidelines state that TSH alone should be used to screen for primary hypothyroidism and to assess the adequacy of thyroid hormone replacement for this condition. In the presence of a normal TSH, which constitutes the majority of cases, fT4 and T3 add little clinical value. In spite of this, fT4 and T3 continue to be frequently ordered in combination with TSH. These inappropriate tests can lead to unnecessary repeat testing, further investigations and referrals, and in some cases, even unnecessary treatments. In select patients, for example, with suspected or known pituitary or hypothalamic disease, where the TSH may not be reliable, a free T4 would be indicated.

Background

A baseline audit showed that over a 20 week period, over 6,500 thyroid function tests were done throughout the Hospital, including both the inpatient and outpatient setting. TSH was ordered along with another thyroid hormone test (fT4, T3 or a combination) 71% of the time. A normal TSH was observed in 79% of cases. 71% of fT4 and T3 tests were likely unnecessary as the corresponding TSH was normal.

Implementation

In order to reduce unnecessary thyroid hormone testing and promote a more TSH-centered approach, a laboratory reflex fT4 system has been implemented within the Hospital, whereby a fT4 is automatically reported should the TSH result fall outside the normal range. Based on review of the literature and consensus from key stakeholders in the Division of Endocrinology and Department of Laboratory Medicine, a list of appropriate indications for fT4 and T3 tests have been incorporated into fT4 and T3 orders and ordering providers must select an indication to proceed. Current recommendations and explanation of the new reflex system are now clearly outlined on all TSH, fT4 and T3 orders within Epic.

Results

The above interventions were implemented simultaneously. Following their implementation, the number of fT4 tests ordered per week decreased by 41% and the number of T3 tests ordered per week decreased by 66%. These effects have been sustained.

While the management of febrile neutropenia in cancer patients has been well studied with clear practice guidelines, the management of previously healthy, immunocompetent children with a febrile illness and first episode of neutropenia is often similarly followed with empiric broad-spectrum antibiotics and hospitalization. However, multiple studies have shown that healthy, immunocompetent children are at low risk of serious bacterial infections if well appearing with a short history of neutropenia (often viral induced). Less aggressive management should be considered in these otherwise well-appearing, previously healthy patients with suspected viral induced, febrile neutropenia if clear clinical criteria are met, including that the rest of the blood counts and blood smear are entirely normal.

Background

In 2019, a group of key stakeholders (Haematology, General Pediatrics, Infectious Disease and Antimicrobial Stewardship) developed a guideline for management of febrile neutropenia in healthy children.

Implementation

The guideline was launched in the Emergency Department in January 2020 and shared with the Hematology and Pediatrics departments. Reminders are sent when the guideline is not followed and low-risk patients are receiving antibiotics and/or being admitted unnecessarily.

Results

The rate of admission and/or use of antibiotics in low-risk patients with a first episode of febrile neutropenia has decreased from 84% to 33%.

Urine amino acids (UAAs) are often ordered erroneously by clinicians not familiar with this test. This has led to unnecessary testing, mounting costs, false positive “non-specific” results requiring repeat testing, and patient safety events from delays in ordering the correct test. There are only a handful of indications for ordering UAAs, such as Lysinuric Protein Intolerance (LPI), Cystinuria, Hartnup disease, and Fanconi renotubular syndrome. UAAs should not be confused with similar-sounding investigations that are part of the basic metabolic work-up: plasma amino acids and urine organic acids.

Background

In 2020, a quality improvement (QI) team developed a study to optimize the way that urine amino acid tests are ordered at SickKids.

Implementation

In 2020, the working group initiated a series of QI steps to achieve their aim. These steps include the following: 1) Adding more easily searchable synonyms for a test that is commonly mistaken for urine amino acids, i.e. serum amino acids. 2) Removing urine amino acids from Sick Kids Epic hypoglycemia order sets. 3) Adding a warning to the urine amino acid Epic order and requiring a specific indication for the test to be ordered.

Results

Not yet available.

Children presenting to the Emergency Department (ED) with fever without a source is very common in the first 2 years of age. As part of the diagnostic process, UTI often needs to be considered. Since this age group is usually not able to provide a midstream ‘clean catch’ sample, a culture is sent generally using a sterile approach (catheterization or suprapubic aspiration) to avoid contamination and false positive cultures. These options are invasive and painful and can be time consuming in a busy ED. Prior studies have shown that a two-step approach, with dipstick urinalysis performed on a sample that is collected in a urine bag, with an invasive culture sent only if the screening urinalysis test was positive, significantly reduced the catheterization rate in febrile children 6-24 months of age without prolonging ED length of stay and with no missed UTIs. Reducing automatic catheterization for the diagnosis of UTI in this age group will not only decrease the number of invasive, painful and time-consuming procedures, but will also decrease the number of unnecessary urine cultures sent, and the potential consequences of contamination, return visits and unnecessary antibiotic treatment.

Background

Prior to this quality improvement (QI) campaign, there were many practice variations amongst providers when screening for UTI in febrile children ages 6-24 months. However, in the majority of cases in our ED, a sterile urine sample was obtained primarily through catheterization for children not toilet trained as the initial approach, yet only 16.78% were positive for a UTI.

Implementation

Beginning in July 2019, a multidisciplinary QI team was formed with the aim of decreasing the number of unnecessary urine catheterizations in febrile children aged 6-24 months in the ED without impacting LOS, return visits or missed UTI diagnoses. After process mapping to develop a two-step screening pathway that would fit our local context and educating staff, urine bags were expected to be placed, when clinically indicated by specific identified inclusion criteria. Urinalysis was completed from the bag specimen once the healthcare provider had assessed the child and confirmed the need to rule out UTI. If the bag urine dipstick was positive, a second urine sample was collected via catheterization, for repeat urinalysis and culture. Additional optimization strategies include regular communication with nursing and medical teams, modifications in the physician electronic orders, printed workflow charts posted in the ED in high-traffic areas, reminder infograms with inclusion criteria at the bedside and a urine bag kit stocked in each room for improved care flow and access of materials. A written and visual parent resource has also been developed to explain the two-step process to families and aid in facilitation of obtaining a timely urine sample. Lastly, plans are underway to extend these improvements to the inpatient pediatric units.

Results

Since project initiation in July 2019, the ED catheterization rate for UTI screening decreased from 73% to 53% and the number of urine cultures sent to Microbiology decreased by 23%. The average number of monthly catheters completed over a 15-month period has decreased from 126 with a positivity rate of 17%, to 96 with positivity rate of 19%. There was no significant change in ED LOS or return visits over this period. To date, approximately 35 children a month have been spared a catheterization, which is halfway to the goal of a 50% reduction, meaning ultimately it will be closer to 70 children a month once this goal is achieved.

Choosing Wisely news

“Say Nay to the X-ray”: A new toolkit to reduce unneeded ankle X-rays and send paediatric patients home faster

Research at SickKids shows the vast majority of paediatric ankle injuries are low risk and don’t require X-rays during emergency department visits.

Go to article

SickKids launches third phase of Choosing Wisely recommendations to curb unnecessary tests and treatments

SickKids is launching a third list of Choosing Wisely recommendations to address the potential overuse of tests and treatments received by patients at the hospital.

SickKids named a Level 3 Choosing Wisely Canada Hospital

SickKids has been recognized as a Level 3 Choosing Wisely Canada Hospital for building an organization-wide culture of reducing unnecessary tests and treatments.

SickKids study leads to new practice point for assessing management options for newly diagnosed, typical immune thrombocytopenia

Engaging families in shared decision making is essential to examine the benefits and limitations of each treatment option for patients with newly diagnosed, typical immune thrombocytopenia (ITP).

Less is more: new review suggests paediatricians should think twice before routinely testing for respiratory viruses

With an increased emphasis on ‘choosing wisely’ and reducing unnecessary medical tests across the medical field, SickKids paediatricians examined the benefits and limitations for a specific type of test and reviewed the scientific evidence as to when it is actually helpful in improving patient care.

Ontario paediatric emergency departments order fewer low-value imaging tests than US counterparts

Lower use of imaging tests in Ontario paediatric emergency departments was not associated with higher rates of poor outcomes, suggesting that use may be safely reduced in the United States, according to a new study by researchers at ICES and SickKids.

SickKids study finds blood tests alone may be effective strategy for detecting cancer relapse in certain patients

In some types of cancers, tumour markers will decrease with treatment and are helpful in predicting outcomes, which is why researchers at SickKids set out to discover if tumour markers could adequately detect cancer relapse independently of imaging tests.

Growth plate fractures in children’s ankle injuries are much rarer than previously thought

A new study led by SickKids found that lateral ankle injuries in children without X-ray evidence of a fracture are most often sprains that can be easily treated with a removable splint.

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