When Back to Baseline Is the Goal: COVID-19 Impact on Viral Testing in Pediatric Urgent Cares

Purpose/Objectives: Acute upper respiratory infections (URIs) are the most common reason for pediatric urgent care (UC) visits. Respiratory pathogen PCR panels can identify infectious etiology for many common viruses and some bacteria, but utility is limited by their relatively high cost and narrow impact on clinical management. Targeted individual pathogen testing becomes more cost effective when indicated for treatment considerations. In January 2020, we began our Quality Improvement (QI) project to reduce viral panel testing in patients presenting with URI symptoms by half from a baseline of 10 swabs per 1000 respiratory visits. However, the COVID-19 pandemic brought a heightened interest in identifying viral etiologies and a discomfort with diagnostic uncertainty which directly impacted our QI project.

Design/Methods: This QI project occurred in a network of 7 pediatric UC sites affiliated with a large academic children’s hospital. Our interventions focused on clinician education with audit and feedback as the key drivers. Clinician education outlined viral panel testing cost ($682) compared to individual COVID-19 ($100) and influenza ($32) testing as well as the limited utility of panel results. Audit and feedback began in September 2020 and provided clinicians individual scorecards reflecting their viral panel ordering rate and rank compared to peers. We monitored the number of viral panel tests ordered per respiratory visit monthly using a Shewhart u-chart, using statistical process control methods to track improvement over time.

Results: Viral panel testing more than doubled early in the COVID-19 pandemic from 9 tests per 1000 respiratory visits to a new mean of 23 tests per 1000 respiratory visits. COVID-19 was added to the respiratory panel in June 2020 and was the fastest means to a COVID-19 test result until rapid tests became available in our UC centers in October 2020. With clinician scorecards and rapid COVID-19 testing availability, respiratory panel testing quickly trended back towards baseline and was approaching our goal with a new mean of 5.4 tests per 1000 respiratory visits.

Conclusion/Discussion: External factors often impact the aim and results of QI projects. Respiratory testing increased during the COVID-19 pandemic due to institutional testing capability and protocols which required us to adapt our QI project to the changing landscape of testing needs. While the full impact of the COVID-19 pandemic on our QI project is difficult to determine, we anticipate that our QI initiatives will contribute to a sustained drop below baseline pre-pandemic viral testing rates.