P0128 - Evidence-Based Standardization of Constipation Management in the Pediatric Emergency Department: A Quality Improvement Study

Background
Constipation is a common problem in pediatric patients. Abdominal radiographs (AXRs) are frequently obtained in the pediatric emergency department (PED) for diagnosis despite their poor reliability to rule out underlying pathology or prognostic ability to determine the degree of constipation. The goal of this quality improvement (QI) initiative was to standardize the diagnosis and management of constipation in the PED and Urgent Care (UC) in patients ages 6 months to 21 years as well as to decrease AXR use.

Methodology
This prospective QI project involved a multidisciplinary team at a large urban pediatric tertiary care center. The team distributed an anonymous needs assessment survey via e-mail to all pediatric emergency medicine providers to identify practice patterns and perspectives on the utility of AXR for patients with constipation. A key driver diagram was constructed and interventions identified such as creation of a standardized algorithm, education using free open access medical education platforms (FOAM), incorporating the EMR interface, and expanding educational conferences to include standardized approach and discharge instructions for patients with constipation across all acuity levels. The main measure of AXR utilization was tracked over time on a statistical process control chart to evaluate the impact of interventions.

Results/Discussion
A majority of survey respondents (98%) felt confident in diagnosing constipation clinically. However, about 67% of respondents used AXRs to rule out other diagnoses and provide reassurance to families. Prior to implementing this qualitative improvement project, AXRs were obtained in 49.6% of patient visits for constipation. A total of 7518 visits between July 2017 and December 2019 were included. Of those, 5194 visits were to the PED and 2324 visits were to UC locations. The proportion of visits for constipation that included an abdominal radiograph decreased from a baseline of 49.6% to 37.1% (Figure 1). The proportion of visits with outpatient prescriptions written for polyethylene glycol increased from 44.3% to 50.1% (Figure 2). Special cause variation was demonstrated in October 2018, shortly after the needs assessment survey was completed. Length of stay, return visits within 7 days, and inpatient admissions remained unchanged by the interventions.

Conclusions
The implementation of a collaborative QI project decreased the proportion of AXRs during visits by pediatric patients for constipation, without a significant change in LOS or rate of 7-day return visits. After providing a needs assessment survey to determine key areas of improvement, a diverse array of educational interventions was used not only to decrease AXR use, but to help with provider education and outpatient management for families. Retrieving further data from respondents such as provider type/role and years of experience may lead to additional targeted interventions.