Elsevier

The Journal of Pediatrics

Volume 225, October 2020, Pages 109-116.e5
The Journal of Pediatrics

Original Article
Reducing Abdominal Radiographs to Diagnose Constipation in the Pediatric Emergency Department

Portions of this study were presented at the Academic Pediatric Association Region IX and X Annual Meeting, January 26-27, 2019, Monterey, California; at the American Academy of Pediatrics CA2 Advances in Pediatric Symposium, March 2, 2019, Studio City, California; and at the Pediatric Academic Societies annual meeting, April 24-May 1, 2019, Baltimore, Maryland.
https://doi.org/10.1016/j.jpeds.2020.06.028Get rights and content

Objective

To determine the frequency of abdominal radiographs obtained in healthy children aged 6 months to 18 years to diagnose constipation in a pediatric emergency department, and evaluate the impact of quality improvement (QI) interventions on their use.

Study design

QI study over 2.5 years at a large urban quaternary care children's hospital emergency department. Interventions consisted of educational presentations and individualized abdominal radiograph data reporting. The primary outcome measure was the percentage of abdominal radiographs performed on healthy patients discharged home with a diagnosis of constipation before and after QI interventions.

Results

The baseline total percentage of abdominal radiographs performed in otherwise healthy children discharged home with a diagnosis of constipation was 36% (October 2016 to January 2018). According to questionnaire results, ruling out obstruction was the most common reason for ordering an abdominal radiograph. After the QI interventions, the total percentage of abdominal radiograph decreased to 18% (April 2018 to March 2019). This 18% decrease was significant (P < .001) and sustained over a 12-month follow-up period. Throughout the study period, the average length of stay was 1.07 hours longer for children who had an abdominal radiograph. Clinically important return visits to the emergency department were uncommon during the postintervention phase (125/1830 [6.8%]), and not associated with whether or not an abdominal radiograph was performed at the initial visit.

Conclusion

After these QI interventions, we noted a significant and sustained decrease in the percentage of abdominal radiographs obtained for otherwise healthy patients discharged home with a diagnosis of constipation.

Section snippets

Methods

Our institution is a 495-bed, urban, freestanding quaternary care children's hospital located in Los Angeles, California. Our PED has more than 90 000 visits annually, and is staffed by pediatric emergency medicine (PEM) attendings and fellows, urgent care pediatricians, pediatric nurse practitioners, and resident physicians. Our PED is geographically separated into 2 sections. One area is staffed by PEM attendings and fellows along with resident physicians. The other section is staffed by

Results

During the 30-month study period, there were a total of 5696 encounters by 5084 patients meeting our inclusion criteria, with an average of 190 ± 31 encounters per month, in which an otherwise healthy child was diagnosed with constipation and discharged home. Before, during, and after the QI interventions, the Cohen Kappa for encounter exclusions was at least 0.80, which indicated an acceptable level of agreement beyond chance. Of the total 5084 patients seen, 2820 patients (55.5%) were female.

Discussion

Our division's baseline percentage of performing abdominal radiograph for healthy children discharged home with a diagnosis of constipation was low, at only 36%, than most other previously published studies, where the baseline abdominal radiograph rate ranged between 27% and 90%.6,17, 18, 19, 20, 21, 22, 23, 24 Despite our institution's lower baseline rate, our QI interventions still resulted in a significant decrease in abdominal radiograph use in the diagnosis of constipation, from 36% to 18%

Data Statement

Data sharing statement available at www.jpeds.com.

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    The authors declare no conflicts of interest.

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