PC1226: De-implementation and Diagnostic Stewardship: Reducing Unnecessary Erythrocyte Sedimentation Rate (ESR) Ordering in a Children's Hospital Using Electronic Clinical Decision Support

Purpose/Objectives: In recent years, several de-implementation initiatives have focused on diagnostic testing. One such initiative, the Choosing Wisely campaign, recommends against routine use of erythrocyte sedimentation rate (ESR) for assessment of acute undiagnosed inflammation or infection. With the development of newer biomarkers of inflammation, particularly C-reactive protein (CRP), there is a decreasing role for ESR in screening for acute-onset conditions; however, ESR continues to be commonly ordered.

We examined ESR and CRP ordering practices at a large, tertiary care children's hospital from July 2019 to July 2020 and found that 80% of ESR orders were placed concurrently with a CRP order. Furthermore, during the start of the COVID-19 pandemic, the baseline ordering rate of ESR rose from a mean of 28.7 to 49.4 ESR tests per 1000 Emergency Department (ED) visits, reflecting a 72% increase from pre-pandemic baseline. Similar increase was seen in the inpatient setting (59% increase from pre-pandemic baseline).

Our aim was to reduce the ESR ordering rate by 20% in 6 months in inpatient and ED settings.

Design/Methods: We utilized the Lean A3 model for process improvement to assess ESR ordering practices by conducting stakeholder interviews and creating a driver diagram. We initially provided education in the ED and general pediatrics divisions along with subspecialty groups (Infectious Diseases, Rheumatology, Gastroenterology) who were deemed by our initial analysis to be high users of ESR tests (November 2020 through March 2021). We then embedded an electronic clinical decision support within the ESR order to provide guidance for ED and inpatient providers (April 22, 2021). We selected CRP testing rate as our balancing metric to assess if this intervention would lead to an increase in CRP testing.

Results: Six months after the interventions, the ESR ordering rate decreased from 11.4 to 8.9 tests per 1000 patient days in the inpatient setting and from 49.4 to 29.5 tests per 1000 ED visits in ED setting, reflecting a 22% and 40% decrease in ESR ordering rates, respectively. This change has been sustained into the 11th month post-intervention. There was no change in the CRP testing rates after interventions.

Conclusion/Discussion: Education and clinical decision support interventions were effective in reducing ESR ordering rate in inpatient and ED settings at a large stand-alone children’s hospital. This was effective even in the setting of the COVID-19 pandemic that saw a rise in ESR ordering associated with multisystem inflammatory syndrome in children (MIS-C) that currently requires ESR as part of the evaluation process. The clinical decision support has been particularly effective in sustaining this de-implementation effort for almost one year post-implementation.