Reducing Unnecessary Imaging for

Patients With Constipation in the

Pediatric Emergency Department
Catherine Craun Ferguson, MD,​a Matthew P. Gray, MD,​a Melissa Diaz, BS,​a Kevin P. Boyd, DOb

OBJECTIVES: Constipation is a common diagnosis in the pediatric emergency abstract

department (ED). Children diagnosed with constipation may undergo an
abdominal radiograph (AXR) as part of their diagnostic workup despite
studies that suggest that an AXR in a patient suspected of being constipated
is unnecessary and potentially misleading. We aimed to decrease the
percentage of low-acuity patients aged between 6 months and 18 years
diagnosed with constipation who undergo an AXR in our pediatric ED from
60% to 20% over 12 months. aDepartment of Pediatrics, Medical College of Wisconsin,
Milwaukee, Wisconsin; and bChildren’s Hospital of
METHODS: We conducted an interventional improvement project at a large, Wisconsin, Milwaukee, Wisconsin
urban pediatric ED by using the Institute for Healthcare Improvement’s
Dr Ferguson conceptualized and designed the
Model for Improvement. The primary outcome was the proportion of study, drafted the initial manuscript, and revised
patients ultimately diagnosed with constipation who had an AXR during the manuscript; Dr Gray informed the design of the
their ED visit. Analysis was performed by using rational subgrouping and study, reviewed and revised the manuscript, and
assisted with data analysis and chart creation;
stratification on statistical process control (SPC) charts. Ms Diaz aided in data collection and helped to
RESULTS: Process analysis was performed by using a cause-and-effect draft the initial manuscript; Dr Boyd informed
the design of the study and reviewed and revised
diagram. Four plan-do-study-act cycles were completed over 9 months.
the manuscript; and all authors approved the
Interventions included holding Grand Rounds on constipation, sharing best final manuscript as submitted and agree to be
practices, metrics reporting, and academic detailing. Rational subgrouping accountable for all aspects of the work.
and stratification on SPC charts were used to target the interventions to DOI: https://​doi.​org/​10.​1542/​peds.​2016-​2290
different ED provider groups. Over 12 months, we observed a significant Accepted for publication Mar 9, 2017
and sustained decrease from a mean rate of 62% to a mean rate of 24% in Address correspondence to Catherine Craun
the utilization of AXRs in the ED for patients with constipation. Ferguson, MD, Department of Pediatrics, The
Medical College of Wisconsin, 999 N 92nd St, Suite
CONCLUSIONS: The use of rational subgrouping and stratification on SPC C550, Milwaukee, WI 53226. E-mail: cferguson@mcw.
charts to study different ED provider groups resulted in a substantial and edu
sustained reduction in the rate of AXRs for constipation. PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online,
1098-4275).
Copyright © 2017 by the American Academy of
Pediatrics
The overall use of diagnostic imaging commonly seen problems, such as
for pediatric patients presenting to constipation, bronchiolitis, and FINANCIAL DISCLOSURE: The authors have
indicated they have no financial relationships
the emergency department (ED) is ankle sprains, is also detrimental relevant to this article to disclose.
increasing.‍1,​2‍ This increased use is to both the patient and to the
FUNDING: No external funding.
despite the pervasive concern that health care system at large.‍3 As
nonessential imaging increases the overuse in medical care becomes POTENTIAL CONFLICT OF INTEREST: The authors
have indicated they have no potential conflicts of
cost of medical care and exposes more widely recognized as a interest to disclose.
pediatric patients to unnecessary significant issue in the United
radiation. Although the use of States, there are calls for quality
computed tomography accounts improvement (QI) efforts aimed To cite: Ferguson CC, Gray MP, Diaz M, et al. Re­
for much of this increase and at reducing the inappropriate ducing Unnecessary Imaging for Patients With
Constipation in the Pediatric Emergency Depart­
exposure, the overutilization of plain use of diagnostic tests and ment. Pediatrics. 2017;140(1):e20162290
radiographs for the diagnosis of treatments.‍3,​4

Downloaded from www.aappublications.org/news at Indonesia:AAP Sponsored on March 1, 2021

PEDIATRICS Volume 140, number 1, July 2017:e20162290 QUALITY REPORT
As part of a broader aim to improve
the effectiveness of care provided
in our pediatric ED by decreasing
unnecessary imaging tests for
common diagnoses, we looked at
our utilization rate of abdominal
radiographs (AXRs) for patients
diagnosed with constipation.
Constipation is a leading cause of
acute abdominal pain in childhood
and has a significant impact on ED
utilization and the cost of health
care.‍5–‍ 7‍
In a 2014 clinical guideline, the North
American and European Societies
of Pediatric Gastroenterology,
Hepatology, and Nutrition found
that the evidence supports not
performing an AXR to diagnose
functional constipation.‍8 Similarly,
a National Institute for Health and
Clinical Excellence workgroup
determined that AXRs should not
be used to diagnose constipation.‍9
Both groups instead advocate
the use of a careful history and
physical examination to diagnose
functional constipation. These
recommendations were based, in
part, on studies that revealed that the
inter- and intraobserver agreement
on the existence of constipation on
AXR varies between the radiographic
scoring system used‍10 and that
AXRs have limited value in the
evaluation of children with suspected
constipation.‍11,​12 Recent studies
showed that AXRs performed in
the ED for constipation resulted in
increased return visits to the ED for
the same problem.‍13 Perhaps more
troubling, the sole use of AXRs may
lead to significant misdiagnoses in
pediatric patients discharged with
the diagnosis of constipation, in
part because plain radiographs are
often normal in patients with major
abdominal diagnoses.‍14,​15
‍ system and individual provider level.
The few studies that describe the
ED management of children with
constipation highlight the variability
in approaches to the diagnosis and
treatment of this common problem
and reveal that between 50% and
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e2
70% of children seen in the ED for
constipation undergo an AXR as
part of their workup despite the
lack of support for their utility.‍16,​17
‍ and family practice residents;
To our knowledge, there is no
published literature on applying QI
methodology to the management
of constipation in the pediatric ED
setting.
Consistent with these studies,
we found that during a 7-month
preintervention period, 800 low-
acuity patients (Emergency Severity
Index [ESI] levels 4 and 5) were
diagnosed with constipation and
63% of these patients received an
AXR during their visit to our pediatric
ED. On the basis of the guidelines and
existing literature outlined above,
we determined that our performance
was not in line with best practice. The
rationale for our project was that if
providers in our ED understood that
constipation can be safely diagnosed
clinically without an AXR and
were aware of how many patients
currently undergo AXRs for this
purpose that our overall utilization
of AXRs for this patient population
would significantly decrease. The
specific aim of this project was to
decrease the percentage of low-
acuity patients (ESI levels 4 and 5)
between 6 months and 18 years of
age diagnosed with constipation who
have an AXR in the pediatric ED from
62% to 20% over a period of
12 months.
Methods
Context
The Children’s Hospital of
Wisconsin is a 296-bed tertiary
care children’s hospital located
in Milwaukee, Wisconsin, and is
affiliated with the Medical College of
Wisconsin. The 36-bed ED receives
>64 000 annual visits. There are 2
geographically separate sections of
the ED. The “Green” section of the
ED houses 22 beds and is staffed
by pediatric emergency medicine
(PEM) physicians, PEM fellows, and
advanced practice providers (APPs)
24 hours per day. Trainees include
pediatric, emergency medicine,
medical students; nurse practitioner
students; and physician assistant
students. Trainees perform histories
and physical examinations for the
majority of patients presenting to
the Green ED before staffing with an
attending or fellow. Decisions about
whether to obtain imaging studies
are ultimately made by the staffing
PEM attending or fellow. APPs staff
emergent patients (ESI levels 1–3)
with faculty or fellows and care for
urgent patients (ESI levels 4–5)
on their own. Between 1000 and
0030 every day of the week, lower-
acuity patients may be seen in the
14-bed “Gold” section of the ED,
which is staffed primarily by general
pediatricians and APPs who make
the decision about whether to obtain
imaging studies.
Interventions
To decrease the number of patients
diagnosed with constipation who
receive an AXR during their ED visit,
we assembled a multidisciplinary
team including 3 PEM physicians,
1 general pediatrician, a pediatric
gastroenterologist, a pediatric
radiologist, and a medical student.
In addition to a current-state
assessment, the team obtained
background information between
June and October 2013 through
a review of the literature, 1-on-1
interviews, and a series of meetings
and e-mails with section faculty
members. This information was
used to map the process of caring
for patients with constipation in the
ED and create a cause-and-effect
diagram to identify barriers at the
The team then created a key driver
diagram and initially prioritized a
large-scale educational intervention
and metrics reporting.
Project implementation began in
January 2014 with a section-wide
Ferguson et al
Grand Rounds educational
presentation led by a PEM attending
(C.C.F.), a hospital-based pediatric
gastrointestinal subspecialist, and a
hospital-based pediatric radiologist
(K.P.B.). On the basis of our key
drivers, the primary objectives of
this educational intervention were
as follows: (1) to inform providers
of the indications for an AXR and
the pitfalls of obtaining an AXR for
the diagnosis of constipation, (2) to
review the use of a focused physical
examination for the diagnosis of
constipation, and (3) to generate a
group discussion around how to talk
with patients and their caregivers
about the risks and benefits of
imaging for abdominal pain when
constipation is the leading diagnosis.
The providers in attendance were
tracked, and annotated PowerPoint
(Microsoft Corporation, Redmond,
WA) slides from the Grand Rounds
presentation were distributed via
e-mail to all ED providers after the
presentation.
Next, we shared the project
dashboard that displayed our
outcome measure on statistical
process control (SPC) charts with ED
providers via e-mail, including PEM
faculty, fellows, general pediatricians,
and APPs. Individual metrics were
also available to those providers who
requested them.
Measures
The primary outcome measure was
the percentage of low-acuity patients
with constipation who had an AXR
in the ED. The analysis included
all patients between 6 months and
18 years of age with ESI levels 4
or 5 who presented with a chief
complaint of constipation or who
were discharged from the ED with
constipation as 1 of the diagnoses
(International Classification of
Diseases, Ninth Revision code 564.xx).
This level of severity was selected
in an attempt to exclude patients
with concerns of an acute abdomen
or other pathology that may have
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PEDIATRICS Volume 140, number 1, July 2017
required an AXR. The providers in
attendance at PEM Grand Rounds
were recorded as a process measure.
Although it was not an intervention
that we implemented for this project,
it should be noted that the number
of shifts in the Gold ED assigned to
PEM faculty and fellows increased
beginning in June 2013. Our team
theorized that this change would
increase the interaction between
the PEM faculty and fellows and the
general pediatricians and potentially
affect our outcome measure
positively. Therefore, the number
of shifts in the Gold ED completed
by PEM providers (PEM faculty and
fellows) every month was tracked as
a process measure.
As a balancing measure, we collected
the number of “bounce backs,​”
defined as patients diagnosed with
constipation in the ED who returned
to the ED within 48 hours during
the pre- and postintervention time
periods for any reason. These charts
were reviewed by the team leader
(C.C.F.) on a monthly basis.
“Gold providers” were defined as
providers (general pediatricians and
APPs) who work exclusively in the
Gold ED. “Green providers” included
PEM faculty and fellows as well as
APPs who work the majority of their
shifts in the Green ED.
Analysis
The proportion of patients who
had an AXR stratified by individual
provider was abstracted monthly
from the electronic medical record.
We used P charts with funnel limits
to identify individual providers
with higher utilization before
implementation and subsequently
to track individual physician
performance metrics. We used run
charts and SPC charts to identify
variations along the project timeline
with implemented improvements
and revised our center line and limits
when special cause became evident.
On the basis of our baseline data
and our hypothesis that there would
be differences in the utilization
of AXRs between the general
pediatricians and the PEM faculty, we
disaggregated the data by provider
type (Green versus Gold providers)
by using rational subgrouping
from November 2012 through
September 2014 to effectively target
our interventions to each provider
group as the project developed. For
analysis, the preintervention period
was November 2012 through May
2013, the intervention period was
December 2013 through May 2014,
and the postintervention period was
June 2014 through September 2014.
We continue to follow the outcome
measure monthly for surveillance
purposes.
The Pearson χ2 test was used
to compare the use of other
imaging modalities in the pre- and
postintervention time periods and
the rate of 48-hour return visits in
patients who had an AXR and those
that did not. Analysis was conducted
with SAS Enterprise Guide 7.1 (SAS
Institute, Cary, NC). This project was
reviewed by The Children’s Hospital
of Wisconsin Institutional Review
Board and determined to be a local
QI project and was classified as
nonhuman subjects research.
Results
On average, 104 (SD: ±13) children
were diagnosed with constipation
each month in our ED during the
23-month study period. As reflected
in the upper and lower control
limits shown in ‍Fig 1, this number
was stable throughout the project
timeline. In the preintervention
period, the utilization of AXRs was
high among both groups of providers,
but a funnel plot indicated that the
highest individual utilizers were in
the Gold provider group (‍Fig 2).
‍ igure 3 shows the main outcome
F
measure stratified by provider type
(Green versus Gold providers). After
the planning period and before any
e3
FIGURE 1
Annotated P chart displaying the AXR rate by month during preintervention, intervention, and postintervention periods (November 2012–January 2016).
The percentages of children (ESI levels 4 or 5) diagnosed with constipation in the pediatric ED who received an AXR (all providers) are shown.

FIGURE 2
P chart with funnel limits displaying the average AXR rate of individual providers over 3 months during the preintervention period (April 2013–June 2013).
The percentages of patients with constipation who received an AXR (by individual provider) are shown.

planned interventions, there was
a decrease in the number of AXRs
ordered by Green providers for
patients diagnosed with constipation
from 54% to 37% (P < .01). There
was an additional decrease in the
Green provider group after the
Grand Rounds presentation. There
were no such decreases in the Gold
provider group during this same time
period. The project team noted that,
whereas 68% of PEM faculty and
fellows and 55% of APPs attended
the Grand Rounds presentation,
none of the Gold providers did
so. This observation informed the
subsequent plan-do-study-act cycles,
which centered on the electronic
distribution of educational materials
and the use of academic detailing (ie,
peer-to-peer educational outreach
aimed at improving clinical practice
in a targeted area).‍18 The academic
detailer chosen for this project is a

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e4 Ferguson et al
FIGURE 3
Side-by-side P charts displaying the AXR rate by month stratified by provider type from November 2012 through September 2014. The percentages of
children (ESI levels 4 or 5) diagnosed with constipation are shown.
general pediatrician with a lower AXR
utilization rate and a member of the
project team. She provided insight
into how Gold providers learned new
information most effectively and spoke
informally with other providers in the
Gold ED during her shifts. After these
interventions, the mean subsequently
decreased in both groups and the
overall mean has remained at 24%
through October 2016.
There was no special cause variation
noted in the number of bounce backs
between November 1, 2012, and
September 30, 2014. Including our
surveillance data collected through
October 2016, 48 of 1624 (3.0%) of
those patients who had an AXR in the
ED returned within 48 hours, whereas
80 of 3198 (2.5%) of those patients
who did not have an AXR in the ED
returned within 48 hours (P = .394).
Although not tracked as a balancing
measure, we found that the decrease
in AXRs did not result in an increase
in other imaging studies for this
group of patients. Before our
interventions, 17 of 672 (2.5%)
included patients had computed
tomography or ultrasound of the
abdomen and/or pelvis in addition
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PEDIATRICS Volume 140, number 1, July 2017
to or instead of an AXR, compared
with 93 of 4150 (2.2%) during the
postintervention and surveillance
periods (P = .675).
Discussion
The preintervention utilization
rate of AXRs for the diagnosis of
constipation in low-acuity patients
presenting to our pediatric ED
was >60%, a rate that seemed
unacceptable given that (1) expert
consensus suggests constipation
should be diagnosed clinically, (2)
there is no reliable radiologic scoring
system for constipation, and (3) AXRs
in children with abdominal pain may
lead to missed diagnoses of more-
emergent abdominal pathology.
Through the implementation
of feasible and cost-effective
interventions over a 12-month
period, we observed a significant and
sustained decrease from mean rate
of 62% to a mean rate of 24% in the
utilization of AXRs for this group of
patients.
What our work also shows is
that, even within a single unit or
department, different types of
providers have varying practice
patterns and may benefit from
interventions aimed at improvement
that are tailored to their specific
needs and training background.
The use of rational subgrouping
and stratification on SPC charts to
analyze these provider groups was
essential to studying and reacting
to these differences and shows
the importance of using these
methods to inform the planning and
implementation of QI projects aimed
at changing practice patterns in the
pediatric ED.
It is interesting to note that the
Green providers, a group made up
predominantly of PEM physicians
and fellows, significantly changed
their clinical practice after the
announcement of the project aim
and before the implementation
of any planned intervention. This
finding may represent the presence
of a Hawthorne effect, the social
phenomenon driven by a desire to
please and meet the expectations
of the researcher, or in this case the
improvement team leader,​‍19 but we
postulate that the rapid change in
provider behavior may be due to
e5
other factors. First, there is a general
sentiment within our provider
group of the merits of decreasing
unnecessary interventions in our
vulnerable patient population, a
sentiment that seems to be shared by
PEM providers as a group.‍20,​21‍ Second,
this change in practice did not place
additional demands on the providers’
time or workload. Third, providers
seemed sensitive to the knowledge
that their performance was being
monitored in an ongoing manner even
though few providers asked for their
individual metrics. Finally, within the
time frame of this project there was
an overall shift toward a culture of
improvement; our capacity for QI was
increasing and became an academic
focus for several of our providers
during this time.
Change in ordering practices of
the Gold provider group, made
up of general pediatricians and
APPs, did not happen as quickly
as in the Green provider group.
The inclusion of Grand Rounds
attendance as a process measure
pushed us to develop alternative
means of distributing educational
materials that were more effective
for this group of providers, a lesson
that has been carried over to other
QI initiatives in the ED. Academic
detailing also seemed to drive change
in this group; however, because these
2 interventions occurred within
the same month, it is difficult to say
with any certainty which had the
greatest impact. For this project,
our academic detailer served as a
role model and provided support to
other Gold providers to improve their
performance during shared shifts.
A formal cost analysis was beyond
the scope of this work. However,
under increasingly common
prospective payment models, any
reduction in resource use would be
expected to yield a cost savings to
the hospital. We used the 2016 global
Medicaid payment for an abdominal
series radiograph (including both
the technical component and
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e6
interpretation) as a proxy for cost. If
sustained, our change in practice for
this limited group of patients would
yield an estimated annual savings for
the hospital of ∼$17 500.
There are limitations to our findings.
We did not include all children with
abdominal pain or all those who
underwent an AXR. It is possible
that some children diagnosed with
constipation in our ED may have
subsequently received care in
another ED or clinic. Although we are
confident in our analysis of the SPC
charts, there was no control group,
so it is possible that improvement
occurred because of a secular trend
toward decreased imaging rather
than as a result of our interventions.
Our findings are important for
PEM physicians and any physician
involved in the care of pediatric
patients who desires to decrease
patient exposure to radiation and
reduce health care waste. The
percentage of children who should
undergo an AXR in the ED when
constipation is being considered is
not known and there is currently no
published benchmark around AXRs
for the diagnosis of constipation. This
study is supportive of reevaluating
not only our use of diagnostic
imaging resources in the ED but the
whole of pediatric quality measures
to provide safer and more effective
health care overall. Our work also
shows that, even within a single unit
or department, different groups
of providers may have different
practice patterns and may benefit
from interventions aimed at QI that
are tailored to their specific needs.
The use of rational subgrouping
and stratification on SPC charts
was essential to identifying these
differences and examining how our
interventions affected each group.
Conclusions
We significantly decreased the use of
AXRs in the diagnosis of constipation
for patients presenting to a pediatric
ED by using simple, cost-efficient
interventions that included provider
education, metrics reporting, and
academic detailing. Formal QI tools
and methods, particularly rational
subgrouping and stratification with
SPC charts, were instrumental in
ensuring that the interventions were
appropriately designed to achieve
a rapid and sustained improvement
in our outcome measure. Our next
steps include working with hospital-
affiliated community pediatricians to
inform their AXR-ordering practices
for patients with constipation,
and we plan to reach out to other
community urgent care centers and
EDs in the future.
Acknowledgments
C.C.F. thanks every one of her
colleagues in the ED at the Children’s
Hospital of Wisconsin for their
willingness to improve.
Abbreviations
APP: advanced practice provider
AXR: abdominal radiograph
ED: emergency department
ESI: Emergency Severity Index
PEM: pediatric emergency
medicine
QI: quality improvement
SPC: statistical process control
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Reducing Unnecessary Imaging for Patients With Constipation in the Pediatric
Emergency Department
Catherine Craun Ferguson, Matthew P. Gray, Melissa Diaz and Kevin P. Boyd
Pediatrics 2017;140;
DOI: 10.1542/peds.2016-2290 originally published online June 14, 2017;

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Reducing Unnecessary Imaging for Patients With Constipation in the Pediatric
Emergency Department
Catherine Craun Ferguson, Matthew P. Gray, Melissa Diaz and Kevin P. Boyd
Pediatrics 2017;140;
DOI: 10.1542/peds.2016-2290 originally published online June 14, 2017;

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by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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