Reducing unnecessary nasopharyngeal virus testing at a tertiary care paediatric centre - A Choosing Wisely initiative
CPS ePoster Library. Friedman J. Jun 1, 2017; 176604
Jeremy Friedman
Jeremy Friedman
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Abstract
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Background: Viral respiratory testing in paediatric patients is commonly performed, however results often do not impact care and the procedure is uncomfortable for children. In 2014, nearly 6000 nasopharyngeal (NP) swabs for direct fluorescent antibody (DFA) testing (8 viruses) were completed with 61% ordered in the Emergency Department (ED) or Paediatric Medicine wards. Approximately 63% of ED swabs were on children discharged home. Since results were not immediately available and no formal follow-up was in place, the test frequently did not affect patient management.

Objectives: To decrease the number of unnecessary NP swabs performed on children in the ED and Paediatric Medicine wards

Methods: A multidivisional expert panel reviewed published guidelines and formulated a pathway listing indications for viral respiratory testing. Two more effective tests were introduced to replace the older DFA test: 1) rapid influenza isothermal amplification that can provide results within 15 minutes and direct timely use of antiviral therapy, and 2) multiplex PCR (15 viruses). As a force function, the electronic order set was modified requiring users to select an appropriate indication. As a hard-stop, the rapid influenza test could only be ordered for inpatients with Microbiologist approval. A multi-faceted educational campaign was launched throughout the hospital. The main outcome measure is the total number of swabs performed, relative to total patient volumes, in the ED and Paediatric Medicine. Process measures include the reported indication for testing, ED and hospital length of stays, admission rates, antibiotic and antiviral usage. Balancing measures include total cost of respiratory testing and rates of nosocomial respiratory virus infection.

Results: Early results indicate that total respiratory virus testing decreased by 41.7% and 32.4% in the ED and Paediatric Medicine respectively, compared with 2014. Testing rates reduced by 16.0% and 28.2% from 2015 rates. Excluding the new rapid influenza test, NP testing dramatically decreased by over 80% in the ED.

Conclusion: Reducing unnecessary viral testing promotes high-value care, decreases patient discomfort and allows for more effective resource allocation of tests that truly impact care. Planning is underway to disseminate this initiative to other hospital areas including outpatient clinics, subspecialty and surgical wards.

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