How to reduce chest radiographs use in bronchiolitis

Despite clear evidenced based international recommendations against obtaining chest radiographs (CXRs) for bronchiolitis, variation in care continues. In some countries such as the USA, it can be over 40%. How can we reduce the ordering of this unnecessary investigation? Just publishing guidelines and updating them is clearly not sufficient to change practice. Frazier Barron S et al (Pediatrics 2021;148:e2020014597) have reduced CXR use for children<2 years with a primary diagnosis of bronchiolitis, from 42.1% to <15% of encounters by March 2020. How did they manage this? They created a multidisciplinary team to standardise bronchiolitis care in their hospital and use quality improvement science methods. Over an 18 year period they had had 12 120 bronchiolitis encounters. Pre-implementation baseline revealed a mean of 42.1% for CXR use. Low reliability interventions, like educational campaigns, resulted in unsustained effects on CXR use. Higher reliability interventions were associated with sustained reductions to 23.3% and 18.9% over the last 4 years. The team involved nurse educators, PEM and hospitalist physicians, a PEM fellow, respiratory therapists, and paediatric residents. Initial interventions were composed of level one reliability interventions, including educational campaigns and the creation of a …