PROPOSAL TITLE: Reducing Unnecessary Respiratory Virus Testing in the Pediatric Emergency Department

PROJECT LEADS: 

• Emily Roben, MD, MS, Director for Quality and Safety, UCSF Benioff Children’s Hospital Emergency Department, Oakland
• Israel Green-Hopkins, MD, Director for Quality and Safety, UCSF Benioff Children’s Hospital Emergency Department, San Francisco

EXECUTIVE SPONSORS:

• Jacqueline Grupp-Phelan, MD, MPH, Division Chief, Pediatric Emergency Medicine (UCSF)
• Karim Mansour, Section Chief of Pediatric Emergency Medicine (Oakland ED)

TEAM:

• Daniel Shapiro, MD, MPH, Assistant Professor of Emergency Medicine, UCSF Benioff Children’s Hospitals
• Rob Lewis, RN, Quality Improvement Specialist, BCH Pediatric Emergency Department
• Yahaira Colorado, RN, Service Line Administrative Director, Emergency Services
• Kate Farley, RN, Unit Director, Mission Bay Children's Emergency Department
• Steven Bin, MD, Medical Director and APeX SME, Mission Bay Children's Emergency Department
• Jim Naprawa, MD, APeX SME, Oakland Children's Emergency Department

ABSTRACT: Testing for respiratory viruses has not been shown to change management or improve clinical outcomes for most children seeking acute care for common illnesses. Accordingly, the Choosing Wisely™ campaign has recommended that limiting the use of these tests should be a national priority. Despite these recommendations, in 2023 respiratory virus tests were performed in 16.3% (N=11,838 tests) of children discharged from the pediatric emergency departments (EDs) at UCSF. The aim of this proposed initiative is to reduce the proportion of children discharged from EDs at UCSF Benioff Children’s Hospitals who have a respiratory virus test performed by 60% (i.e., to 6.5% of encounters) in FY2025. Through a series of interventions including audit and feedback, implementation of a clinical pathway, clinician education, electronic decision support, and electronic order modifications, this project will have an estimated direct costs savings of $261,117 during FY2025.

PROBLEM: Respiratory viruses are responsible for most pediatric emergency visits in the United States.¹ Although testing for and identifying respiratory viral pathogens may provide reassurance for families and diagnostic closure for clinicians, clinical trials and observational studies have demonstrated that respiratory virus testing does not influence management decisions or clinical outcomes for most children.^2-4 At the same time, respiratory virus testing carries financial costs, is physically and emotionally traumatic for children, exposes nurses to respiratory virus particles, may result in false certainty about a viral diagnosis, and may encourage unnecessary healthcare utilization for the sole purpose of obtaining a viral test. For these reasons, the Choosing Wisely™ campaign considers these to be low-value tests in most circumstances.⁵

Despite a lack of evidence to support routine use of respiratory virus tests, these tests are frequently performed in children with and without respiratory illnesses, both nationally and at UCSF. In 46 Children’s hospitals in the United States, the frequency of respiratory virus testing for children discharged from the ED has increased 4-fold in the last 7 years, resulting in monthly charges of approximately $500,000 per hospital.⁶ In children discharged from pediatric EDs at UCSF in 2023, respiratory virus testing was performed in 8,260 (16.3%) of children with any diagnosis and in 4,740 (33.7%) of children with fever or respiratory illness. These findings suggest that there is an opportunity to improve the value of pediatric emergency care by reducing the frequency of unnecessary respiratory virus testing.

TARGET: Our goal is to reduce the frequency of respiratory virus testing in children discharged from pediatric EDs at UCSF Benioff Children’s Hospitals by at least 60% (i.e., to <6.5% of discharges) by the end of FY2025. 

The goal of 60% was chosen based on prior published results of a similar intervention that successfully reduced the proportion with viral testing by >80% at a pediatric emergency department (to a proportion lower than our target of 6.5%).⁷ There were no unintended harms to patients as a result of the intervention. We chose a slightly more modest goal that we felt was achievable, would produce a relevant change, and would account for the unique considerations for our patient population, some of whom have chronic illnesses that may require different considerations for viral testing.

As outlined below, one quantitative benefit of this project is to reduce the direct costs associated with respiratory virus testing by an estimated $261,117. Because the charges for these tests (up to $2,000/test) exceed the direct costs to UCSF ($47/test), we expect the financial cost savings to the healthcare system to far exceed the estimated direct cost savings. Additional qualitative benefits include fewer traumatic nasal swabs for children; less exposure of nursing staff to infectious particles while performing tests; additional time for nursing staff to complete other important clinical tasks; less time spent by laboratory personnel running the tests; and less time spent by ED staff calling families to report test results after discharge. Additionally, if changes in testing practices result in a culture shift away from indiscriminate testing, then families may not present to the ED for the sole reason of obtaining a test for mild, self-resolving illnesses. This could potentially reduce the financial and time costs associated with low-acuity ED visits.

In the comments below, we provide an estimate of time saved by bedside nurses (822 hours/year), lab personnel (843 hours/year), and follow-up nurses (561 hours/year).

GAPS: The table below summarizes the gaps identified, the multifactorial potential drivers of the problem, and the corresponding proposed interventions to address each driver. 

INTERVENTIONS

Practice setting: UCSF Benioff Children’s Hospital EDs, San Francisco and Oakland

Target population: Clinicians caring for children discharged from ED with any diagnosis.

Proposed interventions and rationale: See the table below.

Potential barriers to implementation: Clinicians and parents may have strong preferences for testing, even in cases when testing is not evidence-based. The proposed interventions are designed to provide information to stakeholders and make it easier to forego testing when it is not indicated, while leaving space for stakeholders’ beliefs and preferences to guide individualized care.

Possible adverse outcomes of proposed interventions: Similar interventions in other EDs have resulted in large reductions in viral testing without adverse clinical outcomes. We will monitor rates of ED return visits with/without hospitalization during the intervention period. Additionally, while designing and monitoring the interventions, we will consider potential unintended effects on clinicians such as alert fatigue and task interruption. 

Plan to measure and close equity gaps: The team will measure and monitor the primary outcomes according to patient race, ethnicity, sex, and preferred language. Any identified inequities in testing practices will be communicated to ED attendings at faculty meetings, and efforts to close potential gaps will be developed and incorporated into the interventions.

PROPOSED EHR MODIFICATIONS: The current APeX order set offers 3 options for viral testing: COVID, COVID/influenza/RSV, or comprehensive respiratory viral panel. Clinicians select the order without any guidance on why one (or any) order might be indicated. While any revisions to the order set will depend on insights from focus groups with stakeholders, we will consider using forcing functions, educational decision support, and/or requirements to select/input the rationale for testing prior to placing an order.

RETURN ON INVESTMENT (ROI): The table below includes the estimate for the direct cost savings to UCSF. Given that prior similar efforts have reduced rates of testing by >80%, we believe that these are conservative estimates.

*Based on estimates from Bryson Reedy, senior decision support analyst, UCSF Medical Center 

Based on the estimated number of avoided tests (5,447), the percentage of tests that require additional PPE to be worn by nurses (50%), and the estimated cost of PPE ($1.35/unit), we estimate and additional $3,696 in direct cost savings on PPE. Please see sources for these calculations in the comments.

SUSTAINABILITY: If successful, this intervention will be sustained by the ED’s quality improvement team, led by Drs. Roben and Green-Hopkins. The care pathway for viral testing will be reviewed and updated in the same way that other clinical pathways are updated based on new evidence and invited feedback from stakeholders. Similarly, process and outcomes measures—including equity measures—will be monitored after the funding year. Our Quality and Safety leadership team has a strong foundation in data analytics and cohort monitoring. Accordingly, we are confident in our ability to maintain workflows/analytics and to ensure continuous improvement without the need for additional funding beyond FY2025.

BUDGET:

References:

1. McDermott KW, Stocks C, Freeman WJ. Overview of Pediatric Emergency Department Visits, 2015. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. 2006.

2. Vos LM, Bruning AHL, Reitsma JB, et al. Rapid Molecular Tests for Influenza, Respiratory Syncytial Virus, and Other Respiratory Viruses: A Systematic Review of Diagnostic Accuracy and Clinical Impact Studies. Clin Infect Dis. Sep 13 2019;69(7):1243-1253. doi:10.1093/cid/ciz056

3. Rao S, Lamb MM, Moss A, et al. Effect of Rapid Respiratory Virus Testing on Antibiotic Prescribing Among Children Presenting to the Emergency Department With Acute Respiratory Illness: A Randomized Clinical Trial. JAMA Netw Open. Jun 1 2021;4(6):e2111836. doi:10.1001/jamanetworkopen.2021.11836

4. Mattila S, Paalanne N, Honkila M, Pokka T, Tapiainen T. Effect of Point-of-Care Testing for Respiratory Pathogens on Antibiotic Use in Children: A Randomized Clinical Trial. JAMA Netw Open. Jun 1 2022;5(6):e2216162. doi:10.1001/jamanetworkopen.2022.16162

5. Pediatrics AAo. Choosing Wisely: Five Things Physicians and Patients Should Question in the Practice of Pediatric Emergency Medicine. Accessed February 23, 2023. https://www.aap.org/en/news-room/news-releases/aap/2022/choosing-wisely-five-things-physicians-and-patients-should-question-in-the-practice-of-pediatric-emergency-medicine/

6. Children's Hospital Association, Pediatric Healthcare Information System.

7. Ostrow O, Savlov D, Richardson SE, Friedman JN. Reducing Unnecessary Respiratory Viral Testing to Promote High-Value Care. Pediatrics. Feb 1 2022;149(2)doi:10.1542/peds.2020-042366